Clinical Quality Assurance Specialist

16 hours ago


Baltimore, Maryland, United States CareFirst Full time
About CareFirst

CareFirst is a leading healthcare organization dedicated to providing high-quality services to our members. We are committed to delivering exceptional care and improving the health outcomes of our community.

Job Summary

We are seeking an experienced Clinical Quality Assurance Specialist to join our team. As a key member of our Appeals and Grievance Department, you will play a critical role in ensuring the quality and accuracy of clinical appeals and grievances documentation. Your expertise will help us maintain compliance with regulatory standards and drive continuous improvement in our processes.

Responsibilities
  • Conduct systematic audits of clinical appeals and grievances documentation to identify areas for quality improvement.
  • Trend results of clinical reviews and develop presentations to highlight strengths and opportunities for improvement.
  • Collaborate with training teams, business analysts, and clinical appeals specialists to develop education resources and provide individual support as needed.
Requirements
  • Bachelor's Degree in Nursing or equivalent experience.
  • 5 years of clinical nursing experience, including 3 years of quality auditing and improvement, training, mentoring, coaching, and providing feedback.
  • Strong knowledge of healthcare regulations, including Maryland Medicaid and Medicare standards.
  • Excellent written and verbal communication skills, with ability to present findings and recommendations effectively.
What We Offer

We offer a competitive salary range of $75,888 - $150,722, depending on experience. In addition to your compensation, we provide a comprehensive benefits package, various incentive programs, and 401k contribution programs.

About You

You are a motivated and detail-oriented professional with a passion for quality improvement. You possess excellent communication and interpersonal skills, with the ability to work effectively in a fast-paced environment. If you are looking for a challenging and rewarding career opportunity, we encourage you to apply.



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