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.

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