The Medicare Advantage and Quality Management division drives performance in Medicare Advantage and the care and service delivered to members by focusing on health status, health outcomes, and experience.

The Senior Medicare Advantage and Quality Management Clinical Consultant is responsible for leading and executing quality improvement, risk adjustment and/or plan performance processes including monitoring and reporting of quality, risk and/or performance indicators, applying clinical knowledge as it relates to identifying opportunities for improvement, conducting qualitative barrier analysis, collaborating with business areas to implement strategies for improvement and monitoring impact of initiatives. This position will monitor outcomes of key indicators including health status, health outcomes, member experience and operational metrics and have an in depth knowledge of regulatory requirements. The incumbent will work collaboratively with the internal team to support research and analysis, apply clinical knowledge related to evidence based care, and incorporates policies and practices to ensure execution of a sound program to maintain integrity of internal procedures. The incumbent plays a leadership role and is responsible for maintaining partnerships with business areas and key personnel. The incumbent is also responsible for providing guidance, mentoring, and coaching to Quality Management, Risk and Plan Performance Analysts.

• Bachelor’s Degree in a Clinical discipline (such as Nursing, Allied Health, etc.) or the Health Sciences (Public Health, Health Administration, etc.)
• Multi-State licensure as a Registered Nurse allowing practice in the State of Alabama or a State of Alabama licensure as a Registered Nurse
• Minimum of 4 years of related clinical experience
• Knowledge of the healthcare field, quality improvement strategies, regulations related to quality, methods for data analysis techniques and interpretation
• Experience with project management and continuous improvement, along with organizational and analytical skills in order to independently identify and evaluate opportunities for improvement related to Key Quality Indicators (KQIs)
• Experience presenting data or information for the purposes of proposal or decision making
• Experience developing objectives, setting goals and facilitating plans to achieve desired results
• Strong communication, both orally and written
• High degree of problem solving and diagnostic skills to be used to develop creative, practical, and cost-effective recommendations for improvement
• Excellent interpersonal skills
• Experience negotiating and integrating conflict-management skills into challenging situations
• Proficient in Microsoft Word, Excel and PowerPoint
• Knowledge of clinical coding guidelines preferred
• Knowledge of risk adjustment methodologies preferred
• One or more of the following certifications; Project Management Professional (PMP), Certified Internal Auditor (CIA), Certified Professional in Healthcare Quality (CPHQ), Certified in Health Care Quality and Management (CHCQM), Certified Risk Adjustment Coder (CRC), or Certified Professional Coder (CPC) preferred
• Utilization Management experience preferred
• This position can be filled in the following cities: Huntsville, Montgomery, Florence, Dothan, Birmingham or Mobile

By submitting a job application, I attest that all information to the best of my knowledge is true and accurate. Furthermore, I understand that any information provided by me throughout the job application process is subject to verification including, but not limited to work experience, education, assessment (test) and interviews.
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Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association