• Quality RN

    Job Locations US-VA-Lynchburg
    Job ID
  • Overview

    The Quality Nurse core function includes assuring ongoing organization-wide regulatory and contractual readiness.  Core functions also include full responsibility for all quality related activities to include, but not limited to, reporting 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 Nurse role will be responsible for performing quality reviews and maintaining interdepartmental communication and education related to expected quality standards. The quality nurse will be responsible for conducting provider site visits and travel is required.



    Planning, organizing and coordinating quality review activities to include, but not limited to:


    • Performing quality reviews based upon pre-determined quality indicators to include data aggregation, report development and formulation of recommendations based upon results.
    • Scheduling and coordinating on-site medical record reviews for quality of care investigations.
    • Providing clinical quality management and ad-hoc reporting services, as assigned
    • Working with the quality improvement manager, director and other designated staff to identify and share best practices and opportunities for quality improvement
    • Performing on-site reviews of practitioner/facility offices, including, but not limited to evaluation of physical accessibility/appearance, adequacy of waiting and examining room space, availability of appointments, adequacy of treatment record keeping and clinical medical record reviews.
    • Educating practitioners/providers on policies and standards related to site surveys.
    • Collecting information from practitioners/providers who perform well in particular areas of their practice to serve as “Best Practice” models for other network practitioners/providers
    • Providing support to the Medical Management Department (Utilization Management and Case Management Areas) for departmental quality activities.
    • Acting as a liaison to hospital quality management/risk staff when quality issues are identified on hospitalized member(s).
    • Performing chart reviews for the purpose of follow-up from past fails, review of HEDIS measures against standards, and achievement of performance goals.
    • Investigating Quality of Service and Quality of Care grievances/complaints/issues from members or at the request of one of the Credentialing Committee.
    • Other quality improvement and HEDIS related duties, as assigned





     License/Certification: Current and Valid Registered Nurse with a license to practice nursing in the Commonwealth of Virginia




    • Medical record review and investigation experience
    • Ability to negotiate with practitioners and providers
    • Ability to communicate effectively verbally and in writing
    • Proficient in the use of Microsoft Office Suite and database management
    • Possess knowledge of ICD-9 and CPT4 coding
    • HEDIS experience preferred


    • Clinical background with a minimum of three years’ experience preferably in a managed care environment
    • Minimum of two years of experience performing quality reviews preferred
    • Quality management experience utilizing quality tools for improvement



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


    About Us


    Virginia Premier 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. 


    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.  


    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


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


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