Quality Nurse Specialist (RN) - HEDIS/NCQA
: Job Details :

Welcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you'll find other important information about this position.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 experience2. Knowledge of CMS guidelines, regulations, NCQA and HEDISPREFERRED 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 hireEXPERIENCE:1. Managed Care knowledge or experience2. 2-3 years Quality Management, Quality Improvement or Process Improvement ExperienceCORE 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 care6. 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 programs8. Investigating potential quality of care issues that may affect the quality or safety of the health of members9. Evaluating reports for continued compliance with clinical quality requirements10. 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 environmentSKILLS 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 communication3. Problem solving capabilities to drive improved efficiencies and customer satisfaction4. Attention to detail5. Proficiency with Microsoft Office6. Medicare experience preferred7. Remote for the most part, will have expectations to come in on as-needed basisAdditional Job Description:* FULLY REMOTE* MUST have HEDIS/NCQA experience* health plan experience preferredScheduled Weekly Hours:40Shift:Exempt/Non-Exempt:United States of America (Exempt)Company:PHH Peak Health HoldingsCost Center:405 PEAK Quality Management