Quality Review Nurse; Hybrid

Purpose

The Nurse, Quality Review Utilization Management (UM) evaluates clinical quality and procedures within the Utilization Management program to maximize efficiency, ensure compliance, and optimize patient care and safety. The role supports UM across all lines of business including Medicare, Medicaid and Commercial product lines. The incumbent performs comprehensive audits of utilization management transactions, reviewing systems and procedures to ensure compliance with regulations, accrediting body requirements, and company standards.

Audits focus on regulatory and accreditation standards as well as key risk areas that impact outcomes, compliance and patient safety.

• Reviews pre‑authorization case files, departmental workflows and audits to ensure accuracy and compliance with federal and state regulations, accrediting bodies (e.g. NCQA) and company policies and procedures. Develops and maintains audit tools to measure compliance with UM Standard Operating Procedures, regulatory requirements and accreditation standards. Utilizes these tools to identify quality improvement opportunities, assisting in special projects and departmental initiatives. Contributes to SOP development and supports the creation of new processes and tools to enhance quality improvement.
  
  Monitors UM reports, performing data analysis to identify trends and compliance gaps. Supports external audits and documents audit findings per organization standards.
• Trend audit results and prepare reports and presentations highlighting strengths and areas for improvement. Conducts root‑cause analysis and collaborates on corrective action plans. Monitors effectiveness through follow‑up audits and metric tracking, recommends improvement strategies, and partners with the training team to develop educational resources for UM staff. Provides coaching and feedback, creates and implements quality improvement action plans, monitors progress, and participates in improvement committees.

• Education Level: Bachelor’s Degree in Nursing; or an additional 4 years of relevant work experience in lieu of a Bachelor’s degree.
• Licenses/Certifications: Registered Nurse (State Licensure and/or Compact State Licensure).
• Experience: 5 years clinical nursing experience with a minimum of 3 years in utilization management; at least 3 years in quality auditing, improvement, training, mentoring, coaching and feedback.
• Preferred Qualifications: Master’s degree in Nursing. Demonstrable experience with external audits, regulatory requirements and NCQA accreditation readiness.

$77,256 – $153,439

UM Quality and Reporting

Care First Blue Cross Blue Shield is an Equal Opportunity (EEO) employer. The Company provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Please visit our website to apply:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. Hands are regularly used to write, type, key and handle small controls and objects. Frequent talk and hearing are required. Weights up to 25 pounds may occasionally be lifted.

Must be eligible to work in the U.S. without sponsorship.