Position Summary
The Registered Nurse, Quality Assurance Reviewer will work in conjunction with the Quality Manager and will be responsible for completing quality reviews for the Clinical Services and Provider Relations teams and reporting results. The role supports Quality Improvement Programs related to delegation, accreditation, and regulatory standards. The role will collaborate with Clinical Services, Provider Relations, and Clinical Training teams to improve the quality of the Kidney Health Management program and other clinical programs.
Responsibilities
- Audit clinical documentation and audit calls to provide feedback ensuring that delegation requirements related to NCQA, URAC, and client are met
- Ensure files comply with federal, state, local CMS accreditation standards
- Support clinical operations in pre-delegation, delegation, and accreditation reviews
- Provide support to clinical operations in auditing clinical documentation and member facing calls as part of clinical excellence review initiatives
- Maintain all required quality, organization, and project documentation
- Prepare and audit files based on regulatory, accreditation, and client requirements in a timely manner to provide key stakeholders an opportunity to correct deficiencies before external audits
- Prepare and deliver weekly reporting statistics of audit activities and outcomes
- Assist with health plan interface and participate in prep for external audits of clinical program
- Be a subject matter expert who is able to provide innovative solutions to problems and assist quality improvement initiatives
- Navigate technical applications – Excel, Outlook, PowerPoint, and Word
- Participate in the quality testing of platform and products enhancements of our electronic medical records system
- Other duties as assigned
Requirements
- Must be bilingual English/Spanish
- RN or LPN licensure and a Bachelor’s degree required (8+ years of clinical quality improvement experience will be considered in lieu of degree and/or RN/LPN licensure)
- Three (3) years of healthcare experience in a care management or quality management setting required
- Experience working in electronic medical records, generating reports and analyzing data required
- Knowledge of regulatory, CMS and accreditation agencies (NCQA and/or URAC) strongly preferred
- Knowledge of Care Management and Managed Care setting strongly preferred
- Experience monitoring calls of a clinical staff preferred
Skills
- Effective verbal and written communication
- Advocate and energize a culture of collaboration, positivity, and motivation
- Performance metrics driven
- Ability to manage multiple concurrent deadlines
- Strong organizational skills and attention to detail
- Must be proficient in Microsoft Office: Outlook, Word, Excel, PowerPoint
Travel
No Travel
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