Clinical Quality Specialist RN - Peak Health

About the role

The Clinical Quality Specialist will be an integral member of Peak Health’s quality team, responsible for overseeing performance improvement activities, ensuring regulatory compliance, and supporting initiatives that lead to effective improvements in quality.

In this role, you will support the HEDIS program by assisting with medical record retrieval and abstraction, working closely with providers to ensure accurate and complete documentation, and collaborating with the HEDIS Program Manager and Quality Manager to implement performance improvement initiatives. Additionally, you will be involved in performance monitoring, assessment, and gathering and analyzing data to evaluate outcomes.

Responsibilities

• Plan, design, implement, and maintain a comprehensive program of continuous quality improvement (CQI) through HEDIS compliance rate tracking, trending, and analysis, as well as identifying existing challenges, inefficiencies, and areas in need of improvement or intervention.
• Assume accountability for HEDIS/Stars improvement activities, including medical record review, chart collection, and member or provider interventions or education to improve HEDIS compliance rates for Medicare HEDIS/STARS measures.
• Assist in preparing the annual QI evaluation report and plan/program documents.
• Review medical records and other documentation to ensure quality care is being provided.
• Ensure workflows, policies, procedures, regulatory, and accreditation standards are implemented and maintain compliance for clinical programs.
• Investigate potential quality of care issues that may affect the quality or safety of members' health.
• Evaluate reports for continued compliance with clinical quality requirements.
• Actively participate in quality committee meetings, assist in developing annual work plans, program descriptions, and evaluations.
• Other duties as assigned.

Requirements

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Four (4) years of healthcare clinical experience OR Bachelor’s degree in healthcare or business-related field AND six (6) years of healthcare quality management or performance improvement in a health plan, hospital, or physician practice.

Preferred Qualifications

• Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; currently enrolled in a BSN program with completion within three (3) years of hire.
• Managed Care knowledge or experience.
• Three (3) years of Quality Management, Quality Improvement, or Process Improvement experience.
• Knowledge of CMS guidelines, regulations, NCQA®, and HEDIS®.
• Thorough knowledge of Performance Improvement Projects (PIPs) and ability to apply that knowledge in PIP writing, development, updates, and data analysis.
• Able to work with large data sets, analyze information, and provide recommendations.

Skills

• Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, URAC, and/or NCQA accreditation standards, including HEDIS/STARS.
• Excellent written and oral communication.
• Problem-solving capabilities to drive improved efficiencies and customer satisfaction.
• Attention to detail.
• Proficiency with Microsoft Office.
• Medicare experience preferred.

Schedule

Scheduled Weekly Hours: 40

Work Environment

Standard office environment. This role is primarily remote but may require in-office attendance on an as-needed basis.

The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.