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Clinical Nurse Educator, Consultant
2 months ago
Your Role
The clinical Quality Review team completes internal audits of front-line staff to ensure alignment with department processes and regulatory compliance. Quality Reviewers also provide coaching and work closely with business leaders to drive optimal results. The Clinical Nurse Educator, Consultant will report to the Quality Review Senior Manager. In this role you will develop performance metrics, evaluate performance, and provide coaching to ensure that staff have the skills and knowledge required to be successful in various clinical roles in Medical Management.
Your Work
In this role, you will:
- Perform Utilization Management audits
- Review audit data to identify care gaps, compliance risks, and trends
- Communicate findings to leadership and provide recommendations to mitigate risks
- Design, implement, evaluate and improve audit criteria and coaching strategies to meet the needs of Medical Management clinical staff
- Provide developmental coaching and support to all staff to improve the skills and competencies required to successfully perform work
- Conduct effective presentations relating to Medical Management processes and/or regulatory compliance for clinical staff
- May independently represent the Quality Review department in Medical Management work re-design, process changes and software implementation
- Act as a resource for the training and auditing team
Your Knowledge and Experience
- Current California RN license required
- At least 7 years of experience in managed care or similar complex healthcare environment with a
- Minimum of 1 year experience in Utilization Management required including Concurrent Review, Prior Authorization, or Post Service Review
- Auditing experience preferred
- Strong organizational and/or project management skills to coordinate departmental projects and to perform multiple projects or tasks simultaneously
- Subject matter expert with capability to effectively audit and train all lines of business (Commercial, Federal Employee Program, Medicare, and Medi-Cal)
Pay Range:
The pay range for this role is: $ 109120.00 to $ 163680.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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