Clinical Quality Review Licensed Clinician, Consultant

Your Role

The Clinical Quality Review (CQR) team is responsible for reviewing potential quality of care issues (PQIs) reported by a member, a member representative, or an internal or external partner. The Clinical Quality Review (CQR) Licensed Clinician, Consultant will report to the Manager, Clinical Quality Review. In this role you will be responsible for understanding workflows, procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). In collaboration with our medical directors, you will follow up / report results to the appropriate committees for further resolution. You will work with a clinical team comprised of Registered Nurses (RNs), physicians and administrative staff to ensure operational compliance with timeliness and reporting requirements.You will use your clinical expertise to investigate quality of care issues related to behavioral health care concerns.

Your Knowledge and Experience

• Current unrestricted CA License (LCSW, LMFT, LPCC, Registered Nurse (RN), or PsyD) by the Board of Behavioral Health Sciences required
• Advanced degree commensurate with field is required
• Requires at least seven (7) years of relevant prior experience including 3 years of experience in behavioral health.
• Possess excellent interpersonal, organizational, and communication skills, positive attitude, and high level of initiative
• Ability to identify problems and work towards problem resolution independently, seeking guidance as needed
• Considerable knowledge of a wide range of psychosocial challenges and familiarity with behavioral health diagnoses and treatment
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint