Quality Assurance RN_LTC

Centene Corporation

22h•Remote

About The Position

Centene is seeking a Clinical Quality Assurance RN to review, monitor, and train staff in the Long Term Care Department. This role involves reviewing care management activities and clinical documentation to ensure accuracy and timeliness according to Fidelis Care’s policies and regulatory standards. The RN will also be responsible for creating, analyzing, and reporting metrics, summarizing findings, and providing direct training to staff to ensure competence and improve performance. The position requires field work for reviewing Intake Specialist work, coaching, and providing real-time feedback. The RN will review clinical documentation for quality standards and accuracy, maintain a tracking tool for workflow and documentation performance, conduct monthly one-to-one sessions with nurses, and participate in educational meetings. Additionally, the RN will assist with special projects, act as a liaison between Field Nurses and Nurse Supervisors, gather data for reporting, assist management with remediation areas, and participate in training-related projects, including training new employees. The role also involves preparing reports, highlighting key findings for performance improvement plans, and collaborating with other business units to ensure process and procedural changes are reflected in clinical documentation.

Requirements

Active NY RN License.
Knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS regulations).
Working in a home care environment or as a staff nurse in an acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP); Geriatrics, Medical Surgical Nursing, Case Management or Discharge Planning.
Proficiency with healthcare terminology such as ICD 10 codes, medical abbreviations, medications.
Experience in medical records review, claims processing or utilization and case management in a clinical practice or managed care organization.
Experience analyzing various types of data and processes in a versatile manner including ability to present findings and make recommendations.
Microsoft Excel skills with the ability to edit, search, sort/filter, format/use styles, create tables, calculate data using functions and formulas and create/use PivotTables for analyzing data.
State registration with the Uniform Assessment System (UAS) for long-term care in NY State is required to access for training, testing and system usage.
Employment is contingent on acceptance and continued authorization by the State to have UAS access.

Nice To Haves

UAS experience highly preferred.
Bilingual language preferences: Spanish, Russian, French, Creole, Mandarin, Shanghainese, Suzho, Cantonese, Toishanese, Fujianese, Fukanese, Fuzhounese Hindi, Bengali, Urdu or Nepali.
Certification courses or other higher education in nursing, healthcare administration, business, operations management or other related discipline.

Responsibilities

Conducting Audits of the UAS assessments and related documentation/forms.
Reviewing, monitoring, and training staff in the Long Term Care Department.
Reviewing care management activities/records of the Care Management Teams and/or activities/clinical documentation submitted by the Intake Specialist.
Confirming accuracy and monitoring timeliness in accordance with Fidelis Care’s policies and regulatory standards.
Ensuring adherence to departmental and regulatory data integrity standards and requirements including contractual obligations with State and Federal agencies.
Creating, analyzing, reporting, and maintaining metrics and processes in support of department and all relevant NYS programs and product lines.
Summarizing and reporting findings to applicable management.
Relaying findings directly to staff and partnering with management to directly train and retrain staff.
Ensuring staff members reach a level of competence in their assigned role and devising individual plans to assist staff in reaching the desired level of performance.
Spending time in the field while reviewing Intake Specialist work and actively coaching and developing staff with real time training and real time feedback.
Reviewing clinical documentation to ensure all components of the Member's medical record are completed with quality standards and accuracy following the Company's policies and State regulations.
Maintaining a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings.
Conducting monthly one-to-one sessions with Assessment nurses to provide re-education on best practices and clinical documentation.
Participating in educational and management meetings to improve clinical core measures and RN quality assessment documentations.
Assisting with special projects as assigned to meet departmental goals and policies.
Acting as a liaison between Field Nurses and Nurse Supervisors to improve clinical processes and workflow communication.
Assisting with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings.
Assisting the Manager, as needed, to determine areas that require immediate remediation and assisting Fidelis Care’s employees to stay ahead of changing information while improving the quality and effectiveness of documentation being submitted.
Participating in training-related projects and identifying training sessions that will support staff development as well as assisting with the training of new employees.
Preparing various reports and correspondences as well as providing summary reports to highlight key findings for implementation of performance improvement plans.
Working with colleagues across business units such as Care Management and Regulatory Compliance to ensure that process and procedural changes are reflected in the clinical documentation of the Assessment Nurses’ such as job aids and policies.