Quality of Care and Clinical Review Nurse

Health Care Service Corporation•Nashville, TN

1d•$69,800 - $125,900•Remote

About The Position

Under the supervision of the Quality of Care (QOC) Manager, the QOC Nurse reviews and investigates potential quality-of-care issues in a timely and efficient manner. The role conducts quality improvement and management activities in accordance with applicable state and federal regulatory requirements, including those of the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). This is a remote role that may be performed from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii. Sponsorship is not available. Compensation is $69,800 to $125,900 annually, with exact compensation varying based on skills, experience, and location. The role aligns with an annual incentive bonus plan subject to its terms and conditions.

Requirements

Registered Nurse (RN) with an unrestricted license in the state of operations.
Five years of combined knowledge of healthcare processes.
Knowledge of managed care processes.
Organizational skills and the ability to meet deadlines and manage multiple priorities.
Verbal and written communication skills, including interfacing with staff across organizational lines, members, and providers.
PC experience, including Microsoft Word, Access, and Excel.
Strong knowledge of common patient disease processes and usual methods of treating them.
Thorough knowledge of medical terminology and commonly used equipment.
Ability to effectively evaluate medical records for appropriateness of care.
Ability to assess and judge the clinical performance of physicians and other health professionals.
Strong analytical, assessment, and problem-solving skills.
Effective oral and written communication skills, including explaining complex information and documenting according to standards.
Intermediate skills in Word, PowerPoint, Excel, and Outlook, with basic ability to enter data into and navigate through a database.
Ability to maintain confidentiality of sensitive information related to quality-of-care activities.
Self-directed and able to work independently, using appropriate judgment to seek assistance and ask questions.
Strong attention to detail and work accuracy.

Nice To Haves

Exceptional presentation and facilitation skills, with demonstrated experience presenting quality, clinical, operational, or regulatory findings to leadership, providers, committees, and cross-functional stakeholders.
Strong investigative skills and experience conducting clinical reviews, quality-of-care investigations, root cause analysis, and issue resolution.
Experience developing and delivering training, educational sessions, or presentations to internal and external audiences.
Experience interpreting, summarizing, and communicating complex clinical information, trends, and findings clearly and concisely.
Experience with Quality of Care (QOC), Quality Management, Quality Improvement, Patient Safety, Risk Management, Appeals, Grievances, or related clinical quality programs.
Knowledge of CMS, NCQA, Medicare, Medicaid, and other regulatory requirements related to quality-of-care reviews and investigations.
Demonstrated ability to identify trends, develop recommendations, and present actionable solutions to improve quality outcomes and member experience.

Responsibilities

Review and investigate potential quality-of-care issues in a timely and efficient manner.
Conduct quality improvement and management activities in accordance with state and federal regulatory requirements, including CMS and NCQA requirements.
Evaluate medical records for appropriateness of care and assess the clinical performance of physicians and other health professionals.
Maintain the confidentiality of sensitive documents, records, discussions, and other information generated in connection with quality-of-care activities.
Keep the QOC Manager updated on overall activities, identified issues, and actions to address issues.