CareFirst Careers

Clinical Quality Specialist, RN (Patient-Centered Medical Home)

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Resp & Qualifications

The Clinical Quality Specialist role partners with the Clinical Leadership team and senior Care Coordinators to enable Care Coordinators in care coordination programs to perform high-quality care coordination.  The incumbent will work collaboratively with Training and Clinical Leadership teams to provide feedback to Care Coordinators regarding nursing quality and the practice of care coordination. The Clinical Quality Specialist’s role is to reinforce quality standards and program expectations to the clinical team; support critical-thinking skills; evaluate clinical quality; and give feedback for program improvements.  The Clinical Quality Specialist will act as another resource to the Clinical Leadership team to investigate quality concerns. The Clinical Quality Specialist works collaboratively with the Clinical Leadership team to evaluate and elevate clinical practice.  

Under the general supervision of the Director, Quality and Clinical Practice, the incumbent’s accountabilities may include, but are not limited to, the following:

Extensive quality review and development activities such as:

  • Conducts various quality reviews as directed. Provides review findings in an organized and systematic manner within designated timelines. 
  • In collaboration with the Clinical Leadership team and senior Care Coordinators, proactively provides ongoing in-depth review and evaluation of casework and all care coordination processes including: assisting with identifying appropriate members; writing and activating new care plans; weekly encounter calls; providing support and reinforcing departmental documentation requirements; and identifying meaningful interventions.
  • Observes and assesses Care Coordinator’s ability to engage members in weekly conversations and maintain engagement through the duration of the Care Plan; review the benefits and purpose of weekly calls and behavior change while documenting a clear and concise encounter note.
  • In conjunction with the Clinical Leadership team and senior Care Coordinators, reviews Care Plans written by the Care Coordinator and provides feedback on thoroughness, quality and ways to enhance each.
  • Proactively identifies areas of noted opportunities for improvement of the Care Coordinator. 

Communication about quality findings, including:

  • Proactively establishes and shares an Care Coordinator quality assessment schedule with the Clinical Leadership team.
  • Plans specific presentations and learning opportunities that would help further develop upon the specific program-wide learning gap (for use in refresher days, forums, Care Coordinator weekly calls, etc.).
  • Proactively prepares quality improvement plans, slide decks, data analyses, and other supporting documents for the Clinical Leadership team.
  • Works quickly and efficiently to perform quality reviews and provide feedback to Clinical Leadership team and senior Care Coordinators.
  • Provides summary feedback and tips in writing to the Clinical Leadership team.
  • Collaborates with Training Team Managers to review all suggested modifications to training manuals, standard operating procedures, etc., that may provide more insight and clarity.

Data analysis and reporting, including:

  • Identifies regional quality trends and proactively develops action plans to improve quality metrics.
  • Develops reporting method to track progress on improvement efforts

Professionalism and leadership, including:

  • Upholds the expected standard, regardless of informal workflows or common practices in the field team.  
  • Apprises the Program Director for Quality and Clinical Practice of all quality issues, regardless of the magnitude of the issue.
  • Escalates ongoing quality concerns to the Senior Leadership team.

Required Experience/Skills/Abilities:

Requires a bachelor’s degree in nursing or related field. In lieu of a Bachelor’s degree, must 4 years’ of clinical experience.  Must have RN license in Maryland, DC and Virginia. In addition, must have 1-3 years of management experience inclusive of accountabilities such as quality improvement, training, mentoring, coaching, and providing feedback for improvement.

In addition:

  • Demonstrated ability to plan, organize, and implement and evaluate clinician work in community healthcare settings.
  • Demonstrated ability to present information to large audiences, in small groups, and one to one.
  • Demonstrated ability to synthesize and analyze clinical information.
  • Demonstrated experience utilizing effective interpersonal communication, supervisory, organizational and priority-setting skills.
  • Must be able to turn subjective assessment into objective statements and suggestions to enable quality improvement.
  • Must be able to anticipate necessary steps in a given assignment with minimal direction.
  • Must be able to follow through on assignments.
  • Must be able to conduct rigorous data manipulation, including collection, synthesis, analysis, and dissemination of findings.
  • Must be able to document quality findings in a memorandum format.
  • Must be able to establish effective partnerships with the assigned Clinical Leader and senior Care Coordinators, including scheduling regular meetings, soliciting feedback, and working proactively.
  • Excellent written and oral communication skills along with effective presentation skills. Able to provide verbal and written feedback for improvement.  Includes the ability to formulate actions plans for performance improvement. Must understand the appropriate mode of communication based on the subject matter.
  • Conceptual, analytical, and problem-solving skills in a complex environment are required; tack, diplomacy, and ability to work with individuals in all levels of the organization.
  • Must demonstrate ability to work with confidential information and ability to interact positively with diverse groups/teams.
  • Multi- tasking skills are necessary. Must be able to handle sensitive issues, conflict with or among others, respectively direct and reinforce staff efforts; effectively plan and organize and prioritize work, and to effectively solve unique problems as they arise or identify when to consult supervisor. 
  • Must demonstrate strong influencing skills, particularly with using data to educate and persuade.
  • Must be able to deal with a challenging work environment from time demands and conflicting priorities. 
  • Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.  Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.   Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.


  • Master’s degree in Nursing or related field.
  • Prefer 1-2 years of experience in a CareFirst Care Coordination program either as an Regional Care Director, Care Coordinator Supervisor, Care Coordinator, or trainer.


The physical demands described here are representative of those that must be met by the incumbent to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.

  • Must be able to work in an office setting, primarily seated while performing duties for a minimum of 8 hours per work day.
  • Must be able to provide own transportation to drive regularly to PCMH Forums and to satellite CareFirst Blue Cross Blue Shield offices and/or locations mutually agreed upon by PCMH field team members.
  • Walking and standing is required.  Lift weight up to 25 pounds on occasion.
  • Hands are regularly used to write, type, key and handle or feel small controls and objects.  Must be able to type and to speak on the telephone simultaneously.
  • Must have the ability to communicate verbally effectively. Auditory ability to actively listen.


Department: PCMH Training & Quality

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 5/20/2018

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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