• Quality Nurse

    Job Locations US-VA-Glen Allen
    Job ID
    2018-5023
  • 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 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 conduct provider site visits, Travel throughout the region is required.

     

    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 database on completed quality of care (QOC) issues and validates work with computer generated QOC tracking report, follows up on discrepancies
    • 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
    • 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
    • Leads meetings, gathers educational materials and presents quality data as applicable
    • 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
    • Designs, redesigns, implements and monitors processes that affect member outcomes
    • Performs on-site reviews of practitioner/facility offices related to credentialing and re-credentialing, 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 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 years of 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 REQUIREMENT

    • 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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