Senior Clinical Quality RN - Eastern Missouri - Remote

Primary 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
• Making sure to monitor and review Patient Care Opportunity Reports (PCOR) with providers to help members get preventative wellness and close care gaps
• Supporting health plan initiatives to improve HEDIS rates and reach P4P targets both before and after looking through medical records
• Coordinating both remote and on-site provider medical record reviews to check if providers are following the right standards for documentation, service delivery, billing, and coding practices, and quality standards
• Working with internal health plan partners on clinical quality initiatives, like Performance Improvement Projects (PIPs), data integration efforts with providers, CAHPS, and NPS improvement
• Attending community events when needed to represent the health plan

Required Qualifications

• 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 able to travel up to 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

Preferred Qualifications

• 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