Quality Management Nurse (RN)- Level II

RCM Healthcare Services
Published
November 14, 2020
Location
Wayne, PA
Category
Job Type

Description

Quality Management Nurse (RN)- Level II
Target Salary $90,000 + Excellent Benefits!
Location: Wallingford, CT
(currently employees are working remotely through the end of 2020)

Under the direction of the Director of Quality Management, develops, monitors, and implements quality improvement interventions outlined in the annual work plan approved by the Department of Social Services (DSS) to improve health outcomes of the HUSKY Health patients in Connecticut. Collaborates across departments and with other Quality Management (QM) team members to meet QM reporting deliverables including the QM work plan, Quality Improvement Projects(QIP), the QM Program Description, the QM Program Evaluation as well as other written deliverables requested by DSS. May require active participant in the URAC re-accreditation process and implementation. Responsible for the initial review and implementation of the processes involved in resolving adverse incidents or quality of care (QOC) issues as needed.
Tracks and evaluates trends in QOC reviews when assigned. Identifies outlier providers by QOC trends, and develops and proposes corrective action plans and/or quality improvement activities to improve member safety. Supports the annual HEDIS data collection and reporting processes through chart audits and abstractions that comply with HEDIS measurement and performance criteria; conducts post-HEDIS abstraction chart reviews. Assists with the development and review of the organizations performance targets involving numerous metric stewards including HEDIS, DSS Custom measures, and Adult Core and CHIPRA measures. Develops, coordinates and provides education and training to HEDIS auditors and abstractors as needed. Compliance with the Connecticut Department of Social Services (DSS) contractual requirements and Utilization Review Accreditation Commission (URAC) Health Utilization Management, Care Management and Disease Management standards.

Prepares detailed health outcomes reports including recommendations and appropriate action plans using evidence-based guidelines. Ensures that timely and accurate records are kept of all HEDIS audit activity, follow-up plans and re-audits. May need to collect, review, and submit supporting documentation consistent with the URAC requirements for recertification in Health Utilization Management, Case Management, and Disease Management. For QOC cases, encompasses clinical investigation of all aspects of the case and the summarization of medical records for presentation to the Physician Medical reviewers as assigned. Facilitates the monitoring and compliance of provider corrective action plans. Works collaboratively with the Director of Quality Management, the Medical Director for Clinical and Utilization, and Physician Medical reviewers to resolve QOC issues. Fulfills any other responsibilities as requested.
Provides clinical expertise and guidance on the QM related activities necessary to meet the goals of the organization. Identifies quality improvement opportunities, as well as provider and member interventions for targeted patient populations. Works with the Population Health Management analytic team and IT departments to determine the drivers and/or barriers of measure results as well as define outcomes measures, and develops specifications documents for outcomes reporting. Conducts QOC investigations as needed. Maintains current awareness of contractual requirements, changes and industry trends. Performs provider site visits as required. Collaborates with other departments to ensure contract compliance, consistency of documentation and timeliness of deliverables. Perform HEDIS chart audits and abstractions. Conducts chart reviews.

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