Quality Nurse Specialist - RN, HEDIS, NCQA

Yesterday

Apply Now

Receive Emails with Similar Jobs

Peak Health

WebsiteLinkedInAll Job Openings

Health Insurance • Managed Care • TPA Services • Pharmacy Benefit Management • Third Party Administrator

51 - 200 employees

⚕️ Healthcare Insurance

🤝 Non-profit

Description

• 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. • 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. • Assume accountability for HEDIS/Stars activities. • Assist in preparing the annual QI evaluation report and plan/program documents. • May review medical records and other documentation to ensure quality care. • Able to work with large data sets and analyze information and provide recommendations. • Ensuring workflows, policies, procedures, regulatory and accreditation standards are implemented and maintain compliance for clinical programs. • Investigating potential quality of care issues that may affect the quality or safety of the health of members. • Evaluating reports for continued compliance with clinical quality requirements. • Actively participate in quality committee, assist in developing annual work plans, program descriptions, and evaluations.

Requirements

• 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) • Five (5) years of healthcare clinical experience • Knowledge of CMS guidelines, regulations, NCQA® and HEDIS® • 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 • Managed Care knowledge or experience • 2-3 years Quality Management, Quality Improvement or Process Improvement Experience