Premera Blue Cross Quality Clinical Consultant II in Mountlake Terrace, Washington

Join Our Team: Do Meaningful Work and Improve People’s Lives

Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

As a* Quality Clinical Consultant II (*Clinician),you will be responsible for the clinical support of Quality Improvement activities within the quality program. This Clinical Consultant will primarily concentrate of the needs of our Federal Employee Program (FEP) members within the Clinical Quality Team and the Member Engagement team. The position is responsible for the research and development of Quality and Performance Improvement initiatives and FEP Member Engagement programs as well as providing complex support of Quality of Care (QOC) issues relevant to the Company. The Clinical Consultant collaborates with clinical and non-clinical staff within the program and throughout the Company to achieve departmental, divisional, and organizational objectives.

What you’ll do:

  • Initiate and lead research on emerging clinical healthcare trends relevant to the Company, its stakeholders, and healthcare quality
  • Interact with the Member Engagement team to assist in designing and implementing Member Engagement programs focused on the needs of our FEP population
  • Develop and maintain Quality of Care (QOC) policies, procedures, and recommended practice guidelines
  • Train clinical and non-clinical staff in QOC policies and procedures
  • Determine acceptable QOC production levels
  • Present and educate the Company on findings of clinical quality research, changes in policies, procedures, or guidelines, as well as aggregate reporting of QOC activities
  • Identify and consult with outside counsel regarding suspected, systematic opportunities
  • Lead and participate in cross-functional process improvement teams
  • Review and validate team member assessments prior to submission for physician review
  • Provide tier 2 reviews of QOC assessments that evaluate the quality (safety, efficacy, patient centered, timely, efficiency, and equity) as well as appropriateness of care received with a focus on ensuring best possible outcomes for customers
  • Collaborate with internal physicians and relevant clinical subject matter experts to verify assessments rendered
  • Work together with Credentialing, Legal and Special Investigation functions of the Company
  • Other tasks as assigned

What you’ll bring:

  • Bachelors' degree or four (4) years’ relevant work experience required
  • Current Washington State Nursing License (RN or LPN/LVN) required
  • Five (5) years of clinical experience with two (2) years of experience in a health plan or related field required
  • Masters' degree or eight (8) years’ of relevant work experience preferred
  • Eight (8) years of clinical experience with five (5) years of healthcare research experience preferred
  • Certified Professional in Healthcare Quality (CPHQ preferred)
  • Knowledge relating to the FEP program
  • Ability to assimilate data and information, conduct analyses, identify trends and make recommendations for clinical or administrative process improvement
  • Proven skill to effectively communicate with a variety of audiences both written and verbal
  • Able to manage multiple tasks with strong attention to detail and meeting deadlines
  • Demonstrated initiative and independent decision-making in difficult and complex situations
  • Intermediate skill with Microsoft Office Productivity tools including Outlook, Word, Excel and PowerPoint
  • Ability to work independently and as part of a team
  • Training and mentoring experience
  • Proven knowledge of healthcare quality empirical work, and emergent trends

What we offer:

Premera is proud to offer a comprehensive benefits package including:

  • Medical, vision and dental coverage
  • Life and disability insurance
  • Retirement programs (401K employer match and pension plan)
  • Wellness incentives, onsite services, a discount program and more
  • Tuition assistance for undergraduate and graduate degrees
  • Generous Paid Time Off to reenergize
  • Free parking

Job Title: Quality Clinical Consultant II

Job ID: 11558

Location: Mountlake Terrace, WA

Full/Part Time: Full-Time

Regular/Temporary: Regular

Equal employment opportunity/Affirmative action

Premera is an equal opportunity / affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, national origin, gender or gender identity, sexual orientation, age, genetic information, disability or veteran status. All staff of Premera and its subsidiary companies must demonstrate the legal right to work in the United States. Premera is an E-Verify employer.