Clinical Quality Specialist RN - Peak Health

Remotemid

OtherQuality Specialist

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Quick Summary

Key Responsibilities

The statements described here are intended to describe the general nature of work being performed by people assigned to this position.

Requirements Summary

EDUCATION, EXPERIENCE, CERTIFICATION, AND/OR LICENSURE: 1.

Technical Tools

OtherQuality Specialist

About the Role

~1 min read

The Clinical Quality Specialist will be an integral member of the Peak Health’s quality team. This position is responsible for overseeing performance improvement activities, ensuring regulatory compliance, and other initiatives that lead to effective improvements in quality.

In this role you will support the HEDIS program by assisting with medical record retrieval and abstraction, working closely with providers to ensure accurate and complete documentation and collaborating with the HEDIS Program Manager and Quality Manager to implement performance improvement initiatives. Additionally, the Clinical Quality Specialist will be involved in performance monitoring and assessment and gathering and analyzing data to evaluate outcomes.

Requirements

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1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC) AND Four (4) years of healthcare clinical experience

Bachelor’s degree in healthcare or business-related field AND Six (6) years healthcare quality management or performance improvement in a health plan, hospital, or physician practice.

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

1. Managed Care knowledge or experience

2. Three (3) years Quality Management, Quality Improvement or Process Improvement Experience.

3. Knowledge of CMS guidelines, regulations, NCQA® and HEDIS®.

4. Thorough knowledge of Performance Improvement Projects (PIPs) and is able to apply that knowledge in PIP writing development, update, and analysis of data in PIPs.

5. Able to work with large data sets and analyze information and provide recommendations.

Responsibilities

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1. Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, URAC, and/or NCQA accreditation standards, including HEDIS/STARS.

2. Excellent written and oral communication

3. Problem solving capabilities to drive improved efficiencies and customer satisfaction

4. Attention to detail

5. Proficiency with Microsoft Office

6. Medicare experience preferred

7. Remote for the most part, will have expectations to come in on as-needed basis

United States of America (Exempt)

405 PHH Quality Management