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Quality Management RN

Phoenix, AZ · Healthcare
Quality Improvement RN – Managed Care
Phoenix, AZ
Quality Improvement Nurse Job Summary: 
  • 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.
443.552.7423 (CALL – TEXT – FAX)
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