Note: The job is a remote job and is open to candidates in USA. Blue Shield of California’s Clinical Quality Review team investigates potential quality-of-care issues arising from member grievances and internal referrals. The Clinical Quality Coordinator requests and manages provider medical records and responses to support clinical review.
Responsibilities
- 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 appropriate action
- 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
Skills
- Requires a High school Diploma or GED or 1 year of additional relevant experience in lieu of a diploma
- Requires 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)
- Basic knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA)
Benefits
- This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
Company Overview