Remote New

Clinical Quality Management Auditor

Blue Cross and Blue Shield of North Carolina
$73,698.00 - $117,917.00
parental leave, paid time off, tuition reimbursement, 401(k)
United States, North Carolina
Dec 09, 2025
Job Description Evaluates, analyzes and monitors staff or provider performance to achieve excellence in quality. Provides timely, relevant, accurate, and objective feedback to staff, providers, and the management team which includes a plan of action or recommendations when deficiencies are identified. Acts as technical resource and develops learning solutions that engage the learner and produces desired business goals and objectives. What You'll Do Primarily responsible for HEDIS overreading to ensure accuracy, consistency, and compliance with quality standards Support clinical quality leadership on planning activities and large operational activities; works with Clinical Quality leaders to define success metrics and criteria Analyze reporting and record volumes to ensure program success and collaborate with leadership to modify/redirect activities to meet targets when necessary Performs quality audits of member medical records to ensure compliance with HEDIS specifications Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified Provide timely feedback and recommendations to Clinical Quality Management Consultants based on HEDIS Audits Drive requirements gathering for medical record abstraction tool enhancements and develop, update, and maintain desktop procedures to ensure accuracy, consistency, and compliance with organizational standards Manage IPP STARS Care Gap requests in alignment with Blue Cross Blue Shield Association timelines and key performance indicators Own the endtoend process of initiating, tracking, and resolving support tickets, coordinating tool enhancements, and validating updates through testing in collaboration with vendors and stakeholders May also support ongoing administration of larger and/or more complex programs Coach newer HEDIS overreaders and assist with supplemental ad hoc HEDIS or ad hoc requests, as assigned What You'll Bring RN with 3 years of clinical experience or LPN with 5 years of clinical experience required Must have previous work experience in applicable business area (i.e. HEDIS, Medical Record Review or quality programs) Bachelor's degree or advanced degree preferred Bonus Points Knowledge of clinical quality improvement operations, including HEDIS, Medical quality ratings, strongly preferred Strong analytical, organization, and problem-solving skills Strong written, and verbal communication skills and ability to successfully interact with all levels of management Knowledge of Blue Cross NC or prior healthcare payer experience strongly preferred Experience in conducting patient chart reviews to obtain clinical measures is preferred What You'll Get The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community Work-life balance, flexibility, and the autonomy to do great work Medical, dental, and vision coverage along with numerous health and wellness programs Parental leave and support plus adoption and surrogacy assistance Career development programs and tuition reimbursement for continued education 401k match including an annual company contribution Learn more Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. Based on annual corporate goal achievement and individual performance. $73,698.00 - $117,917.00 Skills