RN Quality Care Coordinator
About The Position
The Quality Care Coordinator develops, implements, and monitors intervention plans and quality-gap closure to reduce medical costs and improve quality ratings. The role supports these goals 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 work 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 is required.
- Current registered nurse licensure in Wisconsin is required.
- At least four years of clinical health care experience as a registered nurse is required.
Nice To Haves
- Bachelor of Science in Nursing is preferred.
- Experience in basic data analysis, quality improvement, HEDIS medical-record review, preventive care, or health-plan work is preferred.
Responsibilities
- Conduct direct outreach to members and/or providers to close quality gaps and maintain or exceed expected population health outcomes per 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 in alignment with industry and regulatory standards.
- Evaluate utilization patterns, medical records, and other metrics to monitor quality and efficiency results.
- Provide clinical support to the appeals and grievance department and quality-of-care complaint process; prepare 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 among families, members, and providers to communicate current or potential issues when needed.
- Develop, review, and revise department policies and procedures, including preventive-services requirements.
- Provide recommendations for preventive-services medicine and evidence-based clinical guidelines; seek approval and monitor relevant updates or 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 be 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
