Clinical Outcomes QM Nurse

Community Health Network of Connecticut, Inc.•Wallingford, CT

About The Position

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking a Clinical Outcomes QM Nurse. Primary Responsibilities: Work collaboratively within the Quality Management (QM) department and across CHNCT to improve clinical outcomes and the quality of care provided to HUSKY Health Program members. Engage in quality assurance activities that adhere to industry standards, support health initiatives, and maintain member safety. Conduct all job functions surrounding quality of care (QOC) issues and adverse incidents (AI) in compliance with the Connecticut Department of Social Services (DSS) contractual requirements and CHNCT’s URAC program accreditation standards. Supports the annual National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) data collection and reporting processes through chart audits and abstractions that comply with HEDIS measurement and performance criteria. Incorporate the Plan-Do-Study-Act (PDSA) Continuous Quality Improvement (CQI) approach into quality improvement (QI) tasks as part of CHNCT’s QM program. Tasks Performed: Request and retrieve medical record documentation from network providers in collaboration with the Population Health Management Coordinator. Investigate and process all aspects of QOC reviews and AI occurrences identified through CHNCT’s claims-based referral system and/or other internal referral venues. Research and review assigned QOC/AI cases with thoroughness and accuracy. Summarize pertinent medical information related to the event for the Physician Medical Reviewers to decipher the findings of the QOC/AI cases. Interface with reporting supervisor, the Director of Quality Management, the VP of Clinical Affairs, and Physician Medical Reviewers to resolve QOC issues in a timely manner as outlined in the organization’s Policy and Procedure on Adverse Incident and Quality of Care Investigations. Document findings and case details in CHNCT’s care management system-tracking database. Track and evaluate data trends in assigned case reviews to support reporting requirements and contract deliverables. Identify outlier providers by data trends and propose and develop corrective action plans and/or quality improvement activities as needed to improve care and assure member safety. Ensure corrective action plans are clear and concise to improve the likelihood of provider adherence to the corrective action plan. Maintain timely and accurate record keeping of all case reviews, HEDIS® audit activity, and corrective action plans in alignment with internal policies and procedures. Fulfills any other responsibilities as requested related to QOC issues, adverse incidents, and HEDIS®, including intra-departmental training on adverse events. Essential Functions: Comprehensive clinical background in nursing and knowledge of QOC and adverse incident criteria. Works with the Population Health Management analytic team and IT departments for trending and reporting needs related to QOC and adverse incidents. Requires critical thinking skills to conduct QOC investigations and chart reviews. Maintains current awareness of contractual requirements, changes and industry trends as related to QOC issues. Performs provider site visits as required. Collaborates with other departments to ensure contract compliance, consistency of documentation and timeliness of deliverables. Performs HEDIS® chart audits and abstractions.

Requirements

Three to five years of clinical nursing experience.
Working knowledge of HUSKY Health programs, QOC incidents, CMS, NCQA. and URAC standards.
Proficiency in computers, electronic health records, data entry, performance dashboards, Microsoft Excel, Word and Outlook
Strong oral and written communication skills with the ability to identify the need to escalate issues as appropriate.
Time management and organization skills are a must.
Attention to detail and thoroughness required.
The nursing license must be current and unrestricted and align with licensing requirements outlined by the CT Department of Public Health.
Active Registered Nurse License

Responsibilities

Work collaboratively within the Quality Management (QM) department and across CHNCT to improve clinical outcomes and the quality of care provided to HUSKY Health Program members.
Engage in quality assurance activities that adhere to industry standards, support health initiatives, and maintain member safety.
Conduct all job functions surrounding quality of care (QOC) issues and adverse incidents (AI) in compliance with the Connecticut Department of Social Services (DSS) contractual requirements and CHNCT’s URAC program accreditation standards.
Supports the annual National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) data collection and reporting processes through chart audits and abstractions that comply with HEDIS measurement and performance criteria.
Incorporate the Plan-Do-Study-Act (PDSA) Continuous Quality Improvement (CQI) approach into quality improvement (QI) tasks as part of CHNCT’s QM program.
Request and retrieve medical record documentation from network providers in collaboration with the Population Health Management Coordinator.
Investigate and process all aspects of QOC reviews and AI occurrences identified through CHNCT’s claims-based referral system and/or other internal referral venues.
Research and review assigned QOC/AI cases with thoroughness and accuracy.
Summarize pertinent medical information related to the event for the Physician Medical Reviewers to decipher the findings of the QOC/AI cases.
Interface with reporting supervisor, the Director of Quality Management, the VP of Clinical Affairs, and Physician Medical Reviewers to resolve QOC issues in a timely manner as outlined in the organization’s Policy and Procedure on Adverse Incident and Quality of Care Investigations.
Document findings and case details in CHNCT’s care management system-tracking database.
Track and evaluate data trends in assigned case reviews to support reporting requirements and contract deliverables.
Identify outlier providers by data trends and propose and develop corrective action plans and/or quality improvement activities as needed to improve care and assure member safety.
Ensure corrective action plans are clear and concise to improve the likelihood of provider adherence to the corrective action plan.
Maintain timely and accurate record keeping of all case reviews, HEDIS® audit activity, and corrective action plans in alignment with internal policies and procedures.
Fulfills any other responsibilities as requested related to QOC issues, adverse incidents, and HEDIS®, including intra-departmental training on adverse events.
Comprehensive clinical background in nursing and knowledge of QOC and adverse incident criteria.
Works with the Population Health Management analytic team and IT departments for trending and reporting needs related to QOC and adverse incidents.
Requires critical thinking skills to conduct QOC investigations and chart reviews.
Maintains current awareness of contractual requirements, changes and industry trends as related to QOC issues.
Performs provider site visits as required.
Collaborates with other departments to ensure contract compliance, consistency of documentation and timeliness of deliverables.
Performs HEDIS® chart audits and abstractions.