Clinical Quality Coordinator, Intermediate

Your Role

The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Sr. Manager, Clinical Quality Review. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high\-performing teams, getting results the right way, and fostering continuous learning.

The Clinical Quality Review (CQR) Department investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Clinical Quality Review Manager. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff.

Your Work

In this role, you will:

• Request medical records and/or response requests from providers fax, secure email, or remote electronic medical record system
• Validate provider contact information and update department repository accurately
• Follow up on medical records and/or response requests via phone or email and implement Manage incoming medical records/responses accurately and timely
• Review medical records upon receipt for content prior to sending for clinical review
• Follow up with provider if records are incomplete
• Consult with CQR Lead/RN as needed on requests and request status
• Prioritize tasks and assignments to meet turnaround time goals
• Research provider and member information using internal applications (claims, PCP information, plan type)
• Be an active team member and promote a positive work environment
• Provide input for continuous process improvement
• Enter accurate data into department database to ensure accurate reporting
• Work under limited to moderate supervision on routine tasks
• Deliver on day\-to\-day objectives which impact the overall of department goals
• May provide guidance and assistance to new or entry level staff
• Participate in audit preparation activities

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires basic job knowledge of systems and procedures obtained through prior work experience or education
• Typically, requires a minimum of 3 years of prior relevant experience
• Strong verbal and written communication skills
• Basic knowledge of PC\-based software including Microsoft Suite and Adobe Acrobat
• Basic knowledge of managed care principles and benefit plans per line of business (HMO, PPO, Medicare) preferred
• Basic knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) preferred

Hybrid Virtual Work

This role allows employees to work virtually full\-time, however employees will be expected to come to the office based on business need.

ABOUT THE TEAM

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community\-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

* Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.

* Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.

* Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in\-person collaboration with flexibility \- providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in\-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member\-facing roles should work with their manager to determine in\-office time based on business need.
• For employees with medical conditions that may impact their ability to work in\-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well\-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment \- roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork \- Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.