Capital BlueCross, headquartered in Harrisburg, is the leading health solutions and insurance company in Central Pennsylvania and the Lehigh Valley. A partner in the community’s health for nearly 80 years, Capital BlueCross offers health insurance products, services and technology solutions that provide peace of mind to consumers and promote health and wellness for our customers.
The position ensures that care and services assigned to us (specifically in areas of Mental Health, Substance Abuse, Pharmacy/Specialty management, our 24- hour NurseLine and other related vendors) meet our standards and satisfy the performance requirements as determined by federal and state regulations. Will monitor and audit to ensure compliance with all CMS requirements for First Tier/Downstream/Related Entities and NCQA accreditation requirements, and oversee internal clinical activities between Capital and specified vendors. Position involves scheduling and completing of all delegated oversight audits, analyzing vendor reports and activities, and presenting results to various committees involved in accreditation and regulatory standards. Will also oversee documentation of records/ reports/correspondence and prepare NCQA documentation of assigned standards.
Ideal candidate will be an RN with a current license and 5+ years of recent clinical experience and 2+ years in a quality improvement role. Must have knowledge of federal, state, Medicare, and accreditation requirements for delegation oversight and clinical programs; knowledge of accreditation and regulatory standards associated with PA Department of Health NCQA, CMS, and URAC; background with the philosophies and product offerings pertaining to mental health/substance abuse/pharmacy services; previous health plan/managed care experience; familiarity with Medicare vendor requirements and NCQA standards; and strong communication/organizational skills. Experience in quality improvement preferred.
We offer a highly competitive, market-driven compensation/ benefits plan. Apply at: https://www.capbluecross.com/careers
Capital BlueCross demonstrates leadership in creating a culture of employee health and well-being. We received the 2016 American Heart Association platinum level Fit-Friendly Worksite award and the Innovation award and were named #3 on Training Magazine’s list of the top 125 globally ranked training programs.
We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, disability, veteran status, or marital status. EOE/AA.
Additional Salary Information: Very attractive, market-driven compensation/benefits plan.