Resp & Qualifications PURPOSE... The Quality of Care Nurse will effectively identify, prioritize and respond to high level grievances, complaints and complaint appeals from the member or member's authorized representative for the Medicaid and Medicare Advantage lines of business. The incumbent reviews and interprets the grievance or complaint, medical and dental records, narrative notes, in-patient/office policies and all documentation submitted or collected by the plan pertinent to the issue. The incumbent will also understand the merits of legal and accreditation actions. ESSENTIAL FUNCTIONS: Reviews all member grievances or complaints and complaint appeals concerning the quality of care provided by facilities or practitioners. Contacts members, providers, or other parties involved, as appropriate, verbally and in writing to obtain additional information regarding the complaint. Reviews medical and dental claims information and records, and member and provider correspondence to conduct patient care investigations and renders an investigative finding. • Provides detailed written and/or verbal responses to members, providers, and authorized representatives upon completion of a thorough investigation. Responds to follow up questions or concerns with members, providers, and other parties involved in the investigation, as appropriate. • Prepares training materials and serves as the professional resource for all quality of care complaints and quality of care appeal complaints. • Conducts or participates in nursing research as appropriate. Completes medical research by defining and interpreting medical language, defining and interpreting medical procedures and medical/hospital office policies. • * Assists with the preparation of regulatory reports by detailing and summarizing the merits of legal or accreditation actions. QUALIFICATIONS: Education Level: High School Diploma or GED. Experience: 5 years Clinical experience in direct health care or health insurance payor setting working with quality reporting, or analytics. Preferred Qualifications: • 3 years' experience in Quality Initiatives, Medical Review, Utilization Management or Case Management or similar Managed Care organization or hospital preferred. • Working knowledge of NCQA standards. Bachelor's degree in Nursing • Knowledge, Skills and Abilities (KSAs) • Demonstrates excellent written and oral communication skills along with effective presentation skills. Able to provide verbal and written feedback for improvement. Must understand the appropriate mode of communication based on the subject matter. • Computer proficiency and technical aptitude with the ability to utilize MS Office (Excel, Word and Outlook) and web based technology. • Ability to exercise sound judgment in making critical decisions. • Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems. • Knowledge of patient rights and laws relative to those rights, such as HIPAA. • Ability to effectively communicate and provide positive customer service to every internal and external customer. • Proficient in standard medical practices and insurance benefit structures with the ability to use them in varied situations. Licenses/Certifications RN - Registered Nurse - State Licensure And/or Compact State Licensure Practice in MD, DC, VA, WV Upon Hire Required. Salary Range: $69,768 - $138,567 Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements). Department Quality and Accreditation (Mar) Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide 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. Where To Apply Please visit our website to apply: Federal Disc/Physical Demand Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly