Virginia Premier Health Plan, Inc.

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Quality Specialist

Quality Specialist

Job Locations 
US-VA-Glen Allen
Job ID 

Job Description


The Quality Specialist core function includes assuring ongoing organization-wide regulatory and accreditation readiness.  Core functions also include full responsibility for all quality related activities to include, but not limited to, accreditation and regulatory efforts associated with or required by the National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), a registered trademark of NCQA, the Department of Medical Assistance Services (DMAS), the Centers for Medicare and Medicaid Services (CMS) and other required entities associated with or required by the State and/or Federal Government. The Quality Specialist shall also be responsible for performing quality reviews, maintaining interdepartmental communication and education related to expected quality standards, and serving as the liaison for regulatory and accreditation quality standard requirements. Occasional travel may be required, including overnight travel




  • Perform quality reviews based upon pre-determined quality indicators to include data aggregation, report development and formulation of recommendations based upon results.
  • Support processes to ensure timely and accurate regulatory reporting.
  • Ensure ongoing compliance to accreditation and/or regulatory standards through auditing, assessment, data collection, tracking, monitoring, analysis and feedback/recommendations on improvements.
  • Develop and monitor the completion of work plans and project plans.
  • Implement activities, interventions, and/or deliverables as defined in the work plans, project plans or other format for departments throughout the organization.
  • Conduct departmental and file audits, as required, and prepare professional, timely audit reports to include outcomes with meaningful recommendations for improvement.
  • Lead accreditation and/or regulatory work teams for departments throughout the organization to ensure ongoing compliance.
  • Conduct internal (e.g., departmental and organizational) and external educational orientations related to quality standards and compliance.
  • Utilize effective communication with internal customers/departments and external customers to accomplish accreditation and/or regulatory goals
  • Assures policies/procedures compliance to regulatory and accreditation requirements.
  • Assures and/or assesses HEDIS related interventions to assure HEDIS rates improvements Continuously identify streamlining opportunities related to the regulatory and accreditation auditing processes to customer and organization-wide customer satisfaction.
  • Support programs related to regulatory surveys, such as CAHPS, HCBS, and Enrollee Satisfaction Surveys.
  • Perform regulatory audits in the field based upon DMAS and CMS waiver assurance guidelines.
  • Assists with training, in-services and quality audits as a result of plan, regulatory or accreditation requirements.
  • Assists with any/other project management duties, including accreditation related duties, as needed.
  • Represents Virginia Premier at Quality meetings and other leadership events as needed.  
  • Maintains current knowledge of Virginia Premier policies and procedures.
  • Participates in continuing education activities, as appropriate.
  • Other quality duties as assigned.



  • Bachelor’s Degree in Nursing preferred.  Bachelor’s Degree in Business, Public or Health Care Administration accepted.
  • Registered Nurse with valid licensure and/or relevant accreditation experience


  • Proficient in the use of Microsoft Office Suite and database management
  • Proficient in the use of Microsoft Project or similar tool preferred
  • Excellent verbal and written communication skills, plus strong organizational skills
  • Ability to plan, prioritize and multitask, while maintaining attention to detail
  • Strong problem solving skills in a fast paced environment
  • Effective group facilitation abilities
  • Ability to interact with varying levels of staff
  • Ability to interact with providers and enrollees
  • Ability to adapt to changing priorities
  • Demonstrate positive interpersonal skills
  • Must be able to travel


  • Clinical background with a minimum of 3 years of experience working in a health care environment. 
  • Minimum of 2 years of experience performing quality reviews preferred.
  • Prior accreditation and/or regulatory experience, especially related to ensuring compliance with state and federal regulations. 
  • Project management skills/experience preferred. 
  • Six Sigma training preferred.


  • Physical health sufficient to meet the ergonomic standards and demands of the position.


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


Our mission is to inspire healthy living within the communities we serve!


About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard

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