LPN - Licensed Practical Nurse - QA Nurse Specialist

Geisinger•Work from home (Pennsylvania), PA

3d•Remote

About The Position

The QA Nurse Specialist manages annual and proactive HEDIS (PAH) populations and Health Choices/Commercial prenatal-postpartum (PNPP) populations as assigned. The role conducts retrospective medical record reviews to collect clinical quality data according to HEDIS/PNPP specifications and standards established by NCQA, CMS, and other regulatory agencies. It collaborates with Health Plan members, primary care providers, and practice-site personnel to support clinical guideline adherence, coordinate services, encourage preventive care, and improve quality outcomes. The specialist manages assigned member caseloads and outreach, documents data in the Quality database, tracks compliance, and intervenes with non-compliant members. The role also contributes to quality-improvement initiatives, educates providers and members about quality standards and preventive guidelines, participates in member appeals when appropriate, identifies process improvements, reports quality or potential fraudulent issues, and refers members to Health and Case Management when appropriate. The position is work from home in Pennsylvania, with travel to assigned provider offices and community outreach events potentially required. Work is typically performed in a clinical environment. The typical schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m., with 40 scheduled weekly hours.

Requirements

Graduate from a specialty training program in nursing.
Licensed Practical Nurse (LPN) license.
At least three years of LPN work experience is stated as required in the job summary.
Minimum of five years of nursing experience is listed as required under Experience.
Familiarity with medical record review and regulatory agency standards.
Computer literacy.
Critical thinking and organizing skills.

Responsibilities

Manage assigned annual and proactive HEDIS (PAH) and Health Choices/Commercial prenatal-postpartum (PNPP) member populations and caseloads.
Conduct member outreach and implement interventions for compliant and non-compliant members to support population outcomes and quality rates.
Review medical records, including physician progress notes, laboratory data, radiology and imaging reports, and consult notes, to collect quality criteria.
Document collected medical record and member data accurately and promptly in the Quality database according to department standards.
Review targeted measures and collaborate with practitioners or members to ensure follow-up care within established guideline timeframes.
Track member compliance reports and contact members, primary care personnel, or facilities as needed to address non-compliance.
Educate and collaborate with primary care physicians and office staff about quality standards, strategies, available Health Plan support, and preventive health guidelines.
Serve as an educator and clinical resource for the Health Choices population on prenatal and postpartum services, risk assessment, care coordination, health and nutrition education, and preventive screenings.
Participate as a voting member in the member appeals process when appropriate and needed.
Identify process-improvement opportunities and assist management with implementation.
Report quality or potential fraudulent issues identified through daily activities.
Refer members to Health and Case Management when appropriate.
Participate in annual educational sessions on regulatory agency standards.
Travel to assigned provider offices and community outreach events when required.

Benefits

Health, dental, and vision benefits starting on day one.
Three medical plan choices, including an expanded network for out-of-area employees and dependents.
Pre-tax healthcare and dependent-care flexible spending accounts and a health savings account.
Company-paid life insurance and short- and long-term disability coverage.
401(k) plan with automatic Geisinger contributions.
Paid time off plan with accrual.
Up to $5,000 in tuition reimbursement per calendar year.
MyHealth Rewards wellness program with a financial incentive.
Adoption and fertility assistance.
Parental leave pay and military leave pay.
Free Care.com membership with discounted backup care.
Employee Assistance Program, including referrals and access to legal guidance, mental health visits, work-life support, and digital self-help tools.
Voluntary benefits including accident, critical illness, hospital indemnity, identity theft protection, universal life, pet, and legal insurance.