• Quality RN

    Job Locations US-VA-Roanoke
    Job ID
    2018-4969
  • 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 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 RN role will be responsible for performing quality reviews and maintaining interdepartmental communication and education related to expected quality standards. 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

     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.

    Qualifications

     MINIMUM EDUCATION REQUIREMENTS

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

     SPECIAL KNOWLEDGE AND/OR SKILLS

    • 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 

     WORK BACKGROUND/EXPERIENCE

    • 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 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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