Clinical Quality Coordinator, Entry

Job Description

Your Role

The Clinical Quality team oversees and is responsible of HEDIS medical record review, pursuit, and overall HEDIS submission. The Clinical Quality Coordinator, Entry will report to the Supervisor of the HEDIS Outreach Team. In this role you will be responsible for conducting provider outreach during the HEDIS season for medical record pursuit and retrieval. Also, participation in Quality initiatives involving member outreach for care gap closure. Responsible for maintaining high productivity and standard work.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

Your Work

In this role, you will:

• Initiate outbound calls to members and providers to collect information and provide care coordination assistance in obtaining services (schedule appointments, provider appointment reminders, coordinate transportation, etc.)
• Educate members on missing care gaps and provide encouragement to obtain missing service.
• Request medical records from PCP/Specialists by fax, remote EMR access or scheduled site visits as needed
• Manage and maintain HEDIS files and medical records
• Provide administrative support, including generating correspondence, organize mass mailings, coordinator schedules and training
• Continued development of understanding of HEDIS hybrid measures and medical record requirements for HEDIS compliance
• Research member claims and encounters to identify accurate pursuit information for medical record retrieval
• Review medical records and identify elements for compliance
• Create and maintain detailed logs of member and provider interactions
• Ability to de-escalate situations
• Assist in onboarding contingent workforce for HEDIS and outreach projects
• EMR and vendor portal medical record retrieval
• Developing understanding of HEDIS pursuit processes relative to pursuit systems and tracking processes
• Developing understanding of outreach and pursuit project intake procedures, schedules, and reporting requirements
• Ability to work independently in a fast-paced environment with minimal errors
  
  

Qualifications

Your Knowledge and Experience

• Requires a high school diploma or equivalent
• Requires limited knowledge of systems and procedures
• Typically, has limited or no prior experience
• Communication and interpersonal skills
• Must be organized with the ability to keep accurate notes and records
• Customer service experience is preferred
• HEDIS knowledge strongly preferred
• Critical thinking skills
• Knowledge of computer applications including Microsoft Word, PowerPoint and Excel. Internet knowledge with the ability to complete searches
  
  

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About The Team

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
  
  

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
  
  

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.