Clinical Quality Improvement Nurse

Medical Mutual•Cleveland, OH

5d•Hybrid

About The Position

Medical Mutual employees must submit their applications through MySource. This is a hybrid-remote role based out of the Brooklyn, OH office, with employees expected to work onsite on designated in-office days each week. Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans. Clinical Quality Improvement Nurse Job Summary: Applies process improvement methods to daily work to comply with National Committee for Quality Assurance (NCQA), accreditation standards and the Centers for Medicare & Medicaid Services (CMS) regulations for quality. Performs medical record reviews to derive analyses and supporting documentation to enhance NCQA, Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star ratings as well as data analysis to recommend and implement process improvement methods and reporting. Supports and collaborates with provider groups to promote quality and oversight of quality vendors.

Requirements

Graduate of a registered nursing program approved by the Ohio Board of Nursing.
3 years clinical experience as a Registered Nurse preferably in a health plan.
Registered Nurse with current State of Ohio unrestricted license
Good project management skills.
Ability to conduct online research for updates of industry best practices.
Intermediate Microsoft Office skills – (Word, PowerPoint, and Excel).
Knowledge of process and performance improvement methods and tools: Plan Do Study Act (PDSA) or Define, Measure, Analyze, Improve and Control (DMAIC).
Knowledge of NCQA, HEDIS and Medicare Star rating, health plan accreditation standards, and CMS regulations for quality preferred.

Nice To Haves

Bachelor of Science in Nursing preferred.
Master’s Degree a plus.
Certified Professional in Healthcare Quality (CPHQ) or Lean Six Sigma certification preferred.

Responsibilities

Collaborates with quality improvement team/management to support the development of studies, education materials, provider engagement, vendor management and quality initiatives that improve the quality of care provided to members across all lines of business.
Applies clinical expertise to collect HEDIS and/or study data through chart review and abstraction
Prepares narratives, reports, graphs, charts, flowcharts, and policy and procedures, to support quality improvement and accreditation activities.
Applies process and performance improvement methods to gain insight and measure effectiveness.
Integrates output of findings into the redesign of a process or clinical practice.
Collaborates cross-functionally to develop and implement project plans.
Performs other duties as assigned.

Benefits

Laptop, monitors, keyboard, mouse and headset provided.
Access to on-site fitness centers or gym membership reimbursement.
On-site cafeteria.
Discounts at many places in and around town.
Opportunity to earn cash rewards for shopping with our customers.
Business casual attire, including jeans.
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance.
Access to an Employee Assistance Program.
Company holidays.
Up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
Parental leave for eligible employees who become parents through maternity, paternity or adoption.
Career development programs and classes.
Mentoring and coaching.
Tuition reimbursement up to $5,250 per year.
Diverse, inclusive and welcoming culture with Business Resource Groups.