Clinical Quality Assurance Auditor (Jackson, TN Region)

R-49086 We are hiring an Clinical Qual Assur Auditor here at BlueCross BlueShield of Tennessee You will play a critical role in ensuring our members receive high‑quality care by reviewing network providers for compliance with internal quality standards and external regulatory requirements, including Medicare, TennCare, and NCQA. In this role, you will work from home while traveling throughout the Jackson region to conduct on‑site provider reviews across all lines of business. You will independently schedule and perform multiple types of reviews using established audit tools aligned with regulatory guidelines and communicate findings and outcomes directly with providers and office staff. You will also support the annual HEDIS project by collecting medical records for hybrid reviews and assisting the supplemental data team. As a regional auditor, you will build strong, trusted relationships with provider offices in the community while serving as a key ambassador for quality. The ideal candidate will hold an active RN license and bring a strong clinical background with an interest in quality, compliance, and regulatory standards. This role is well suited for a self‑motivated nurse who is comfortable working independently in a remote, field‑based environment and traveling locally within the assigned region. Strong communication skills are essential, as the role involves regular, professional interaction with providers and office staff. Note:

• This is a regional, work‑from‑home position with local travel required in the Jackson area. If you are passionate about promoting quality care for our members and collaborating with providers while leveraging your clinical expertise, we would love to connect with you.
• Sponsorship is not available for this role.
• We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members.

Job Responsibilities

• Presenting and communicating audit results to appropriate parties; participates in the development of procedures and standards that support and enhance all lines of business' quality of care goals.
• Schedule and perform routine facility, practitioner site, and medical record reviews, utilizing established clinical audit tools reflective of national accreditation standards and regulatory agency requirements.
• Identifying and evaluating areas of exposure, potential problems and liabilities. Analyze clinical data to improve individual provider compliance with education; provide oversight for regional contract staff and coordinate the effort of retrieval of HEDIS and/or STARS records; complete medical record audits for HEDIS and/or STARS data collection or quality of care reviews as required.
• Providing required documents and consulting support for quality and compliance audits.
• Various immunizations and/or associated medical tests may be required for this position.

Job Qualifications Education

• Bachelor's Degree in Health Care related field or equivalent work experience.

Experience

• 4 years - Health Care experience required.
• 1 year - Managed care experience or experience with Quality Medical Record Review.

SkillsCertifications

• Demonstrated presentation and team facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Excellent oral and written communication skills
• Excellent time and project management skills
• Strong analytical, planning, organizational and research skills

License

• Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements; as defined in the “Use of Non BCBST-Owned Vehicle” Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). *The definition for "routine basis" is defined as daily, weekly or at regularly schedule times. Number of Openings Available 1 Worker Type: Employee Company: BCBST BlueCross BlueShield of Tennessee, Inc. Applying for this job indicates your acknowledgement and understanding of the following statements: BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page: BCBST's EEO Policies/Notices BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.