The Quality Improvement Nurse performs all aspects of the Quality Improvement Program.
The Quality Improvement Nurse will analyze medical charts, trend lines and applicable transparency websites in order to determine whether there are adverse trends and/or sites of excellence.
Facilitates continuous improvement in the health plan delegated networks by providing individualized case review and processing.
Performs clinical reviews by identifying the issues of the case, ordering and collecting needed documents or records, reviewing the case documents, completing a case summary, and either leveling or reviewing the case with the Medical Director as appropriate.
Maintains strict compliance with federal, state and NCQA requirements and guidelines.
Provides complete and accurate documentation of work performed by keying data into specified databases or forms as instructed and reporting any required metrics.
Participates in the Quality Improvement process by identifying problems, examining solutions options, implementing action plans.
Ensure that the health plan and its contracted network provide members with appropriate and timely and quality of care and services.
Quality Improvement Nurse Background:
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
Certified Professional in Healthcare Quality (CPHQ) or similar certification is preferred.
Bachelors of Science in Nursing (BSN) or related healthcare field is a plus.
Roughly 2-5 years acute care clinical nursing experience is required.
Around 3 years of recent experience in Quality Improvement or Quality Management (including HEDIS) at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.