In your field, learning never stops. And neither do you. You are continually pushing yourself to reach higher and go further. To do everything you can to ensure a positive outcome for our patients. Staying on top of your game and persevering in the face of challenge will be a big part of your success. And at every turn, you'll have the support of an elite and dynamic team. Join us in this role and you will use your diverse knowledge and experience to make health care work better for our patients, while doing your life's best work. (SM)
There's energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)
This position will support the Dual SNP(DSNP) program. The position is responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. This role will be responsible for ongoing management of provider practice and community education on state specific quality measures. The Clinical Quality RN will work closely with the quality director to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives.
The Clinical Quality RN will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. This position will also be responsible for direction and guidance on provider-focused, clinical quality improvement and management programs. This role assists contracted providers with analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, STARS, HEDIS, CMS, NCQA and other tools. Position reports to the Quality Leadership of the Health Plan.
This is a field-based role with a home-based (telecommute, work at home) office. You will be spending approximately 75% of the time in the field within an assigned coverage area. Candidates must be willing to travel within the New Castle County, Delaware area.
- Deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
- Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS / STARS for provider and staff education during field visits
- Materials additionally include information from local, state and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
- Serves as subject matter expert (SME) for assigned STARS Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting STARS Measures; consults with vendors to design and implement initiatives to innovate and then improve STAR Measure rates
- Participates, coordinates and / or represents the Health Plan at community based organization events, clinic days, health department meetings and other outreach events focused on quality improvement, member health education and disparity programs as assigned
- Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care
- Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
- Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
- Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides
feedback to appropriate team members where issues are verified and monitors resolution to conclusion
- Based on medical record audit findings, provides follow-up education, practitioner intervention and measurement as needed to drive quality improvement
- Educates providers and office staff on proper clinical documentation, coding and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria
- Supports continuum of member care by identifying members in need of health education and / or services (case management, etc.) and refers members to the appropriate internal departments per policy
- Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with STARS measures and technical specifications
- Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases and researching to identify members' encounter history
- Participates in or coordinates with other department projects as needed
- Needs to works independently and within an integrated team in a highly matrixed environment