RN Quality Care Coordinator
About The Position
The Quality Care Coordinator develops, implements, and monitors intervention plans and quality-gap closure. The role aims to reduce medical costs and improve quality ratings through member and provider engagement, internal quality process improvement, and coordination of clinical intervention strategies. The coordinator conducts HEDIS and year-round medical record reviews and helps ensure that Network Health meets OCI, CMS, and NCQA quality requirements. Candidates must reside in Wisconsin. The position is eligible to be performed from a home office with reliable internet, with occasional travel to the corporate office in Menasha, including on the first day. The schedule is 1.0 FTE, 40 hours per week, 8 a.m. to 5 p.m., Monday through Friday.
Requirements
- Associate Degree in Nursing required.
- Current registered nurse licensure in Wisconsin required.
- At least four years of clinical health care experience as a registered nurse required.
Nice To Haves
- Bachelor of Science in Nursing preferred.
- Experience in basic data analysis, quality improvement, HEDIS medical record review, preventive care, or health plan work preferred.
Responsibilities
- Conduct direct outreach to members and/or providers to close quality gaps and maintain or exceed expected population health outcomes under HEDIS, Stars, and NCQA.
- Create written materials for members, physicians, and other customers, including newsletters, brochures, self-care materials, educational handouts, letters, and telephone scripts.
- Develop and coordinate member-centric programs aligned with industry and regulatory standards.
- Evaluate utilization patterns, medical records, and other metrics to monitor quality and efficiency results.
- Provide clinical support for the appeals and grievance department and quality-of-care complaint process, preparing cases for medical director review when needed.
- Identify opportunities for improvement and implement clinical interventions.
- Prepare and/or deliver presentations for the Quality Management committee, clinic or provider education, and system-wide committees as needed.
- Coordinate, monitor, and document quality interventions and care management programs to promote effective, value-added care and service.
- Collaborate with secondary providers, including Breathe at Ease, Home Telemetry, and Diabetes programs, to coordinate member services.
- Act as a liaison for families, members, and providers to communicate current or potential issues when needed.
- Develop, review, and revise department policies and procedures, including preventive-services requirements.
- Recommend preventive-services medicine and evidence-based clinical guidelines, seek approval, and monitor for updates or relevant changes as assigned.
- Research, submit, and evaluate CMS-regulated quality improvement projects as assigned.
- Implement systems of care that facilitate close monitoring of members and promote early intervention.
- Assist with updating and maintaining the Clinical Integration (CI) manual and related documentation, including reports.
Benefits
- Opportunity to get paid to volunteer in the local community.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
