Quality Nurse Specialist (RN) - HEDIS/NCQA (wvumedicine)

Job Description

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The Quality Nurse Specialist will be an integral member of the Peak Health’s quality team. This position is responsible for overseeing performance improvement activities, ensuring regulatory compliance, and other initiatives that lead to effective clinical resource utilization and improvements in quality. These duties may include but are not limited to HEDIS/Stars oversight, committee support, performance monitoring and assessment, data collection and analysis, and the continual advancement of the quality improvement process to achieve Peak Health’s goals of excellence.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)

EXPERIENCE:

1. Five (5) years of healthcare clinical experience

2. Knowledge of CMS guidelines, regulations, NCQA® and HEDIS®

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire

EXPERIENCE:

1. Managed Care knowledge or experience

2. 2-3 years Quality Management, Quality Improvement or Process Improvement Experience

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Plan, design, implement, and maintain a comprehensive program of continuous quality improvement (CQI)..

2. Must have thorough knowledge of Performance Improvement Projects (PIPs) and is able to apply that knowledge in PIP writing development, update, and analysis of data in PIPs.

3. Assume accountability for HEDIS/Stars activities.

4. Assist in preparing the annual QI evaluation report and plan/program documents.

5. May review medical records and other documentation to ensure quality care

6. Able to work with large data sets and analyze information and provide recommendations.

7. Ensuring workflows, policies, procedures, regulatory and accreditation standards are implemented and maintain compliance for clinical programs

8. Investigating potential quality of care issues that may affect the quality or safety of the health of members

9. Evaluating reports for continued compliance with clinical quality requirements

10. Actively participate in quality committee, assist in developing annual work plans, program descriptions, and evaluations.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.Standard office environment

SKILLS AND ABILITIES:

1. Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, URAC, and/or NCQA accreditation standards, including HEDIS/STARS.

2. Excellent written and oral communication

3. Problem solving capabilities to drive improved efficiencies and customer satisfaction

4. Attention to detail

5. Proficiency with Microsoft Office

6. Medicare experience preferred

7. Remote for the most part, will have expectations to come in on as-needed basis

Additional Job Description:

• FULLY REMOTE
• MUST have HEDIS/NCQA experience
• health plan experience preferred

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

405 PEAK Quality Management