Senior Clinical Quality RN - Eastern Missouri - Remote
About The Position
This role reports to Quality Leadership and is responsible for ongoing provider education related to HEDIS and pay for performance (P4P) measures, as well as state-mandated and accreditation-related quality requirements. The Sr. Clinical Quality RN will serve as a liaison to establish trusting relationships with MO C&S providers to problem-solve and provide resources to support improved member quality outcomes. This role will also support additional health plan initiatives such as medical record reviews, external quality audits, and clinical data integration. If you live in Missouri, and willing to travel 25%25 of the time to cover Eastern Missouri, you will have the flexibility to work hybrid as you take on some tough challenges.
Requirements
- Current unrestricted RN licensure in Missouri
- 5+ years of clinical experience in any setting
- 3+ years of quality experience (performance improvement, HEDIS performance measures, chart review, team facilitation, etc.)
- Knowledge of one or more of the following: clinical standards of care OR preventive health standards, OR HEDIS, OR NCQA, OR regulatory requirements
- Intermediate proficiency in software applications that include, but are not limited to, Microsoft PowerPoint, Microsoft Word, Microsoft Excel, Microsoft Outlook, and Internet browsers
- Proven ability to interact with internal and external customers in a professional manner
- Proven ability to develop provider relationships
- Proven effective presentation skills and experience providing outcomes data to senior leadership
- Proven self-motivated and have ability to work well both independently and with others as a team
- Willing or ability to travel up to 25%25 of the time to provider locations within a designated area, as well as other areas when needed to meet the needs of the team
- Reside in or within commutable driving distance to St. Louis, MO area, surrounding county in state of Missouri, or the Missouri Eastern Region
Nice To Haves
- Master’s degree
- Managed care experience
- Experience working with Medicaid and/or Medicare populations in a managed care setting
- Experience with Clinical Informatics
- Advanced proficiency in Excel (i.e., pivot charts, graphs, &/or data manipulation and analysis)
- Proficiency in software applications that support HEDIS activities, including but not limited to, Tableau, and vendor platforms
- Proven bilingual - English/Spanish
Responsibilities
- Representing the health plan in meetings with healthcare providers to promote health plan quality initiatives and Value-Based care programs, and to provide needed resources to support improved member quality outcomes
- Monitoring and reviewing Patient Care Opportunity Reports (PCOR) with providers to facilitate member preventative wellness and closure of care gaps
- Supporting health plan initiatives to maximize HEDIS rates and achieve P4P targets both prospectively and during the medical record chase process retrospectively
- Coordinating remote and onsite provider medical record reviews to assess compliance with documentation standards, service delivery, billing and coding practices, and quality standards
- Collaborating with internal health plan partners on clinical quality initiatives, such as those related to Performance Improvement Projects (PIPs), data integration efforts with providers, CAHPS, and NPS improvement
- Representing the health plan at community events when needed
Benefits
- a comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
