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in Woodland Hills, CA

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Verified Pay $85360 - $128040 per year
Hours Full-time, Part-time
Location Woodland Hills, California

About this job

Your Role

The Clinical Quality Review  team Department investigates and reviews potential quality of care issue (PQI) allegations or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Review Nurse (Senior)  will report to the Clinical Quality Review Manager. In this role you will be responsible for reviewing PQI cases per department protocols through various levels of review and executing follow up actions.

Your Work

In this role, you will:

  • Analyze quality issues from both internal and external sources 
  • Determines appropriate level of case review needed which may include escalating cases to a medical director, Peer Review Committee or Credentialing Committee to render a  final determination 
  • Prepare cases for presentation at physician committees as indicated  
  • Prepare corrective action plan requests for cases where it is deemed necessary for the provider to institute a change in their present practices 
  • Present and discuss corrective action plan responses with medical director and/or Peer Review Committee 
  • Thoroughly investigate, apply critical thinking and clinical judgement to appropriately identify quality of care issues  
  • Manage assigned case load to meet all timeliness metrics 
  • Participate in audit preparation activities for the Department of Health Care Services (DHCS) relating to the Medi-Cal population.
At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in , Join us!

Your Knowledge and Experience

  • Requires a bachelor's degree or equivalent experience
  • Requires a current California RN License 
  • Requires at least 5 years of prior relevant experience
  • Requires managed care experience 
  • Requires at least 5 years of experience in clinical setting(s) 
  • Knowledge of regulatory agencies, state/ or federal agency responsible for oversight of  managed care plans   
  • Proficient in use of PC-based software programs including Microsoft Word, Microsoft Outlook and Adobe Acrobat


Pay Range:

The pay range for this role is: $ 85360.00 to $ 128040.00 for California.


Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.