Clinical Quality Reviewer - Nurse, Senior (HEDIS reviewer)

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. 

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.

Please click here for further physical requirement detail. 

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.

Your Role 

The Clinical Quality Team is responsible for reviewing and abstracting medical records to capture data and to ensure accuracy and completeness. The Clinical Quality Reviewer – Nurse, Senior will report to the Manager, Clinical Quality Analytics. In this role you will be reviewing medical records to support HEDIS and other regulatory audits. This role will require the ability to train others on HEDIS specifications and guidelines. This role will research and create medical record review reports and interpret findings.

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.

Your Work 

In this role, you will: 

• Analyze quality issues from both internal and external sources. Determinates level of severity. 
• Train internal staff as needed
• Be participating in regulatory audits as needed
• Be responsible for working with appropriate departments in the areas of compliance, process improvement, and member/provider satisfaction for all product lines. Reviews, research and responds to customer complaints relating to quality of medical care and service. Recommends and/or implements process improvements related to the potential quality of medical care and service.
• Review medical records and documents to abstract clinical data for HEDIS and other audits while identifying opportunities for process improvements
• Meet daily abstraction and overread goals while maintaining a high accuracy percentage
• Train and advise healthcare professionals and contingent staff on HEDIS and other audit regulatory compliance
• Support collection of medical records and reports

Your Knowledge and Experience 

• Requires current CA RN license 
• Bachelor of Science in nursing or advanced degree preferred 
• Requires a minimum of 5 years of prior relevant experience 
• Experience in HEDIS medical record review required 
• Requires experience in Excel and HEDIS audits
• Desired experience and knowledge of medical record systems and processes 
• Desired knowledge and familiarity in EMR software such as Epic, EClinical Works, Allscripts, NextGen, etc.
• Desired knowledge of ICD-10, CPT, and other modifier codes 

 

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.