Job Description

Your Role

The Clinical Quality Review (CQR) team is responsible for reviewing potential quality of care issues (PQIs) reported by a member, a member representative, or an internal or external partner. The Clinical Quality Review (CQR) Licensed Clinician, Consultant will report to the Manager, Clinical Quality Review. In this role you will be responsible for understanding workflows, procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). In collaboration with our medical directors, you will follow up / report results to the appropriate committees for further resolution. You will work with a clinical team comprised of Registered Nurses (RNs), physicians and administrative staff to ensure operational compliance with timeliness and reporting requirements.You will use your clinical expertise to investigate quality of care issues related to behavioral health care concerns. 

Your Work

In this role, you will:

• Work with administrative staff on request of medical/clinical records. 
• Analyze quality issues from both internal and external sources. Make recommendations for level of severity and forward to a medical director (MD). 
• Prepare cases for presentation at peer review committees for group review of cases at a higher severity level.
• Prepare education letters and corrective action requests for cases in which it is deemed necessary for the provider to institute a change in their present practices, including cases in which members did not receive necessary treatment or treatment received was potentially harmful.
• Correspond to providers regarding corrective actions reviewed.
• Collaborate with team members on cases that have both behavioral health and physical health components. 
• Assist with audit readiness in collaboration with BSC partners. 
• Assist with process improvement and reporting activities.
• Act as subject matter expert to review and evaluate the effectiveness of operational workflows to identify problems and develop improvements, modifications, and enhancements
• Develop and evaluate tools and materials that enhance operating efficiency, accuracy, and technical skill levels of unit staff
• Identify process and control improvement opportunities and provide recommendations that help improve the effectiveness, efficiency and/or economic value of a control or process
• Provide guidance, coaching and training on internal behavioral health clinical quality review processes to other employees across the company as appropriate
• Lead, manage, and execute other special projects and team initiatives as assigned
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

Your Knowledge and Experience

• Current unrestricted CA License (LCSW, LMFT, LPCC, Registered Nurse (RN), or PsyD) by the Board of Behavioral Health Sciences required
• Advanced degree commensurate with field is required
• Requires at least seven (7) years of relevant prior experience including 3 years of experience in behavioral health. 
• Possess excellent interpersonal, organizational, and communication skills, positive attitude, and high level of initiative
• Ability to identify problems and work towards problem resolution independently, seeking guidance as needed
• Considerable knowledge of a wide range of psychosocial challenges and familiarity with behavioral health diagnoses and treatment
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

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