• Quality Registered Nurse

    Job Locations US-VA-Chesapeake
    Job ID
    2018-4967
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on! 

    Overview

    The Quality RN’s 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.

     

    Medical Management

    Medical Management educates members and empowers them to become active participants in their coordinated health care plans.  This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

    Responsibilities

    • 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 improve
    • Develop and monitor the completion of work plans and project pla
    • Implement activities, interventions, and/or deliverables as defined in the work plans, project plans or other format for departments throughout the organizati
    • Conduct departmental and file audits, as required, and prepare professional, timely audit reports to include outcomes with meaningful recommendations for improve
    • Lead accreditation and/or regulatory work teams for departments throughout the organization to ensure ongoing complianc
    • Conduct internal (e.g., departmental and organizational) and external educational orientations related to quality standards and complianc
    • 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 require
    • 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 satisfacti
    • 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 require
    • Assists with any/other project management duties, including accreditation related duties, as neede
    • Represents Virginia Premier at Quality meetings and other leadership events as needed.
    • Maintains current knowledge of Virginia Premier policies and procedures.

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS

    • 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.

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • 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

    WORK BACKGROUND/EXPERIENCE

    • 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 preferred.
    • Project management skills/experience preferred.
    • Six Sigma training preferred.

    PHYSICAL REQUIREMENTS

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

    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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