• Quality RN

    Job Locations US-VA-Glen Allen
    Job ID
  • Overview

    The Quality Nurse supports the Sr. Manager Quality MAPD-STAR and is responsible for performing quality reviews, maintaining interdepartmental communication and education related to expected quality standards.  The department supports the organization’s goal of on-going survey readiness for regulatory and accreditation associated with  National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), a registered trademark of NCQA, the Centers for Medicare and Medicaid Services (CMS) and other required entities associated with or required by the State and/or Federal Government by focusing on quality review audits and responding to results of  quality of care reviews as appropriate. Occasional overnight travel may be required.


    • Performs quality reviews based upon pre-determined quality indicators as indicated by STAR measures; HEDIS measures; NCQA measures and other indicators as determined, analyzes data, generates reports based on findings and submits recommendations based upon results
    • Performs Quality of Care Reviews (QOC) in response to identified QOC issues and communicates results to physicians and other stakeholders
    • Generates Quality Event reports using current computer program, reviews report findings and responds to QOC events and communicates results to appropriate team member(s)
    • Performs medical record reviews on recent expired members per policy guidelines and communicates quality of care issues to physicians, maintains documentation of completed record reviews
    • Maintains data base on completed quality of care (QOC) issues and validates work with computer generated QOC tracking report, follows up on discrepancies
    • Monitors APS and CPS reports via blast DSS reporting to ensure process was followed per policy guidelines
    • Ensures ongoing compliance to regulatory standards through auditing, assessment, data collection, tracking, monitoring, analysis and feedback and recommendations on improvements
    • Collaborates with departmental work teams throughout the organization to ensure ongoing compliance with contractual needs related to quality outcomes and also acts as a resource for other departments as indicated
    • Conducts internal (e.g. departmental and organizational) and external educational programs related to quality standards and compliance as needed
    • Performs on-site survey/audits based on identified quality of care issues and provides education to provider/staff based on identified care gaps
    • Communicates effectively with internal customers/departments and external customers to accomplish population health outcomes and goals
    • Assists with HEDIS related interventions to help improve HEDIS rates
    • Acts as a resource to other departments for HEDIS and STARS measures
    • Collaborates with team members on programs related to regulatory surveys, such as Consumer Assessment of Healthcare Providers and Systems (CAHPS), Health Community Based Services (HCBS), and Enrollee Satisfaction surveys
    • Assists with regulatory audits in the field based upon Department of Medical Assistance Services (DMAS) and Center for Medicare and Medicaid (CMS) waiver assurance guidelines
    • Assists with training, in-services and quality audits as a result of plan, regulatory or population health requirements
    • Evaluates and organizes work and projects in ways that are efficient and effective
    • Represents Virginia Premier at Quality meetings and other leadership events as needed
    • Leads meetings and gathers education materials for meetings as applicable
    • Presents quality data in meetings
    • Generates reports, assimilates data, creates presentations and documents to explain data, and makes connections between evidence-based care and patient outcomes
    • Designs, redesigns, implements and monitors process that affect member outcomes
    • Maintains current knowledge of Virginia Premier policies and procedures, Medicare regulations, STARs measures
    • Participates in continuing education activities, as appropriate
    • Serves as the department’s preceptor for new hires and assist the Sr. Manager in the on-boarding process
    • Participates in organizational quality/performance improvement projects as appropriate
    • Travel to Provider offices occasionally as needed



    • Registered Nurse with valid state licensure required
    • Bachelor’s Degree in Nursing preferred or currently enrolled in BSN program or equivalent
    • Bachelor’s Degree in Business, Public or Health Care Administration accepted
    • Completed at least 6 hours of approved professional development courses


    • 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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