• Quality Registered Nurse

    Job Locations US-VA-Chesapeake
    Job ID
    2018-4968
  • 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 Nurse- supports the Sr. Manager Quality 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, Star Rating measures, the Centers for Medicare and Medicaid Services (CMS), Department of Medical Assistive Services (DMAS) 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. The Quality RN will be responsible for conducting provider site visits and travel is required.

     

    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

    • Performs quality reviews based upon pre-determined quality indicators; HEDIS measures; STAR Rating measures, NCQA measures and other indictors 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)
    • Collects and 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 Star Rating related interventions to help improve HEDIS rates
    • Acts as a resource to other departments for HEDIS and/or 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, timely, 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
    • Educates practitioners/providers on policies and standards related to sire surveys
    • Investigates Quality of Service and Quality of Care grievances/complaints/issues from members or at the request of the Credentialing Committee
    • 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 processes that affect member outcomes
    • Maintains current knowledge of Virginia Premier policies and procedures; Medicare regulations; STARs measures and HEDIS requirements as appropriate
    • 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 processes
    • Participates in organizational quality/performance improvement projects as appropriate
    • Travel to Provider offices as needed
    • Other quality duties as assigned
    • Performs on-site reviews of practitioner/facility offices related to credentialing and recredemtialing, 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.

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS

    • Registered Nurse with valid state licensure required
    • Bachelor’s Degree preferred

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Familiar with the use of Microsoft Office Suite and database management
    • Ability to create basic Word, Excel and PowerPoint documents
    • Basic understanding of HEDIS, STARS measures and/or other Regulatory Requirements
    • Basic understanding of measure report process
    • Good verbal and written communication skills
    • Demonstrates positive interpersonal skills
    • Ability to work well within a team environment

    WORK BACKGROUND/EXPERIENCE

    • Clinical background with a minimum of 3 year experience working in a health care environment
    • Prior population health, accreditation and/or regulatory experience, especially related to ensuring compliance with state and federal regulations 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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