Advanced Search
Title
Company
Description

Location:

Start New Search:

nyc health hospitals
rn long term care
pulmonary rehab
trauma nurse
diabetes education
lucas
registered nurse case manager
doh
hedis
nurse supervisor
health wellness
reviewer
reporter
ltc
tube
chauffeur
nys
electronic medical records
queens
oasis

Clinical Quality Improvement (Registered Nurse)

Share Job
Suggest Revision
MetroPlus Health PlanRussell, IA
  • About NYC Health Hospitals MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
  • As a wholly-owned subsidiary of NYC Health Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • The function of the Clinical Quality Improvement Specialist & Reviewer is to design, implement and evaluate complex quality and process improvement projects required to support public health, HEDIS, QARR, Stars and other regulatory needs for complex chronic care conditions.
  • These functions are carried out in a cost effective and measurable design model.
  • The Clinical Quality Improvement Specialist & Reviewer in accordance with NYS DOHand CMS regulatory guidelines and MetroPlus Health Plan policies and procedures also conducts quality of care (QOC) and critical/adverse incident reviews of clinical interactions and clinical documentation from provider treatment records under the direction of the Plan Medical Director.
  • Job Description Design, implement and evaluate complex quality and process improvement projects required to support public health, HEDIS, QARR, Stars and other regulatory needs to drive specific clinical quality improvement outcomes.
  • Provide clinical reviews of Quality of Care (QOC) and Critical/Adverse incidents in accordance with NYS DOH and CMS regulatory guidelines.
  • - Research, develop and identify internal and external barriers/root causes thataffect the health status of plan members and ensure the implementation of strategies to overcome these barriers.
  • - Develop methods and/or tools to collect and track barriers for targeted members and providers.
  • Methods may include but not be limited to surveys, focus groups, visits to provider offices/hospitals, community events or healthcare organizations.
  • - Create plans/interventions based on barrier, data, and/or competitor analyses, defined project scope and goals, measurable metrics for program evaluations, and projected timelines.
  • - Develop member and provider communications that are clear, direct and actionable.
  • - Apply analytics to identify and target various populations to drive quality improvement and measurable outcomes.
  • - Evaluates interventions for project/intervention continuation and or modification to provide for continuous process improvement.
  • - Develops tools and supports for the physicians, provider groups, etc.
  • relative to measures/desired outcomes for specific diseases to drive quality improvement.
  • - Document findings for each initiative and presents results to applicable departments and management.
  • - Analyze member and provider data for assigned healthcare quality measures and/or population to identify trend and target population/area for quality improvement projects.
  • Data sources and tools may include but not be limited to the following: o Statistically significant changes in rates/stratifications o Member and provider information from government and vendor’s reports and datasets and internal databases.
  • - Perform medical record review, including review of electronic medical records to investigate clinical quality of care (QOC) complaints.
  • Review provider records against clinical and procedural established standards.
  • - Ensure timely and accurate QOC case resolution within NYS DOH and CMS regulatory requirements dependent online of business.
  • - Ensure each QOC review is supported by nationally recognized and accepted sources/clinical practice guidelines.
  • Provide citations and references in support of findings and for use in member communications.
  • - Implement and monitor provider corrective action plans as needed.
  • Ensure provider responses are received timely and actions are implemented.
  • - Collect, analyze and prepare quarterly quality of care report(s) for the Quality Management Committee and Quality Assurance Performance Improvement Committee of the Board.
  • Provide follow-up as requested.
  • - Participate in the recredentialing process by providing information regarding provider QOC complaints, medical record review as needed to track and trend provider careand follow up on provider corrective action plans.
  • Attend Credentialing/Recredentialing Subcommittee meetings monthly.
  • - Track and trend clinical quality of care/adverse incidents from a population perspective and identify opportunities for improvement.
  • - Prepare reports to fulfill CMS reporting requirements for quality reporting including but not limited to Reportable Adverse Events.
  • - All other duties as assigned at the discretion of Quality Management Leadership.
  • Minimum Qualifications Bachelor’s degree in a clinical field required.
  • Advanced degree preferred.
  • Current licensed RN required Must have a minimum of 5 years’ experience in the health care field.
  • Quality Improvement experience in a managed care environment preferred.
  • Superior oral, written and communications skills.
  • Ability to understand and communicate analytic and clinical data to varied audiences.
  • Solid analytical and logical skills paired with strong attention to details.
  • Must be a versatile, quick learner, who is open to change and enjoys the challenge of unfamiliar tasks.
  • Superior project management and documentation skills.
  • Must be action oriented, producing results on projects that require risk taking with minimal planning, while keeping self-control during high activity periods.
  • Ability to function well independently and in team setting.
  • Must be able to make effective and timely decisions by organizing information in a useful manner and orchestrating multiple activities at once to accomplish the goal.
  • Must work effectively with others, fostering open dialogue, accountability and common mindsets within the team.
  • Must have integrity, fostering an honest and trusting relationship with coworkers and management, never compromising the Plan, other employees or self for personal gain.
  • Must seek to continuously improve processes for the benefit of the customer by taking personal responsibility for the resolution of customer services.
  • Must be proficient in Microsoft Word, PowerPoint, Excel and Access.
  • Experience with and proficient in data analysis.
  • Working knowledge of relational database and statistical analyses is a plus.
  • Must be familiar with and have a working knowledge with QI process improvement methodology strategies including but not limited to PDSA and DMAIC. Must be familiar with the HEDIS, QARR requirements.
  • Knowledge and understanding of regulatory requirements, specifically CMS and NYS DOH as they are applied to Clinical Quality of Care reviews.
  • Knowledge and understanding of NYS HIPAA and Privacy Rules.
  • Must possess analytical skills in order to collect, organize and present data in a clear and concise manner.
  • Ability to assess all work and prioritize as necessary to meet reporting timeframes and deadlines.
  • Six Sigma Yellow or Green Belt preferred.

Similar jobs:

Active
  • All Jobs
  • Active
Registered Nurse - Weekly Pay - Per Week
Trusted HealthChariton, IA
Trusted is seeking an experienced nurse for this exciting travel nursing assignment.
$3,270 a week Full-time
Registered Nurse Patient Care Coord / Occupational Health / Clinic Float Nurse
Lucas County Health CenterChariton, IA
The role of the Care Coordinator is to assist the healthcare team including medical providers, patients, and families by coordinating and facilitating patient care leading to the best outcome while providing regular and consistent follow-up during transitions of care with patient, coordinators and other healthcare professionals in other care settings.
Full-time
Travel Registered Nurse RN Long Term Care LTC
One Staff MedicalChariton, IA
Company Description: Skilled Nurses works with complex wound dressings, rehabilitation, tube feedings or rapidly changing health status.
Home Health Registered Nurse Case Manager - Full - Time - 1st Shift
Caregivers of CharitonChariton, IA
We are seeking applicants from all of our service counties: Appanoose, Clarke, Decatur, Jasper, Keokuk, Lucas, Madison, Mahaska, Marion, Monroe, Poweshiek, Union, Warren, Wayne.
Home Health Registered Nurse Case Manager - Full - Time - 1st Shift
Midwest HealthChariton, IA
We are seeking applicants from all of our service counties: Appanoose, Clarke, Decatur, Jasper, Keokuk, Lucas, Madison, Mahaska, Marion, Monroe, Poweshiek, Union, Warren, Wayne.
jobsearcher.com/blog
How do Good Interviewers Prepare for Interviews?

Just like candidates take the time to research you and your company, you should take the time to prepare for the interview. Preparing for the interview doesn't just reflect well on your employer brand and create a better candidate experience. Preparation also helps prevent bad hiring decisions. Bad hiring decisions are usually a result of poor execution during the hiring process. However, going into an interview fully prepared and ready to evaluate candidates will help avoid bad hires. So, here are 6 interview preparation tips for employers.

RN ER / Float Nurse
Phaxis - NursingChariton, IA
We at Phaxis are looking to fill a position for an ER Float RN in Chariton, IA

Latest Blog Posts:

jobsearcher.com/blogHow to Utilize Keywords for Your Job AdsBefore we give you the scoop on how to utilize keywords in job ads, it would be helpful if we defined what keywords are and why they are important. In simple terms,
jobsearcher.com/blogHow Far Back Should a Resume Go, Exactly?If you’re reading this article, then chances are you’re looking for a new job and want to whip your resume into shape. But lots of questions can arise as you begin to do that. After all, most of us aren’t career coaches or resume experts. One common question that job hunters frequently ask is: how far back should a resume go? As in, should you list all of your work history – even if it stretches on for years – or should you be more selective?
jobsearcher.com/blogStructured vs Unstructured InterviewsThe goal of an interview is to evaluate candidates based on their skills, personality, and knowledge. You want to choose the BEST candidate from your candidate pool, so the interview is something you can't mess up. As you begin planning your interview process, one of the major decisions you'll face is whether the interview should be a structured vs unstructured interview. So let's take a dive into the differences and sort out which circumstances warrant which interview process.
jobsearcher.com/blogHow to Describe Your Personality with ExamplesImagine you’re in an elevator with the CEO of your dream company and you get to talking. The conversation is going well and you start to imagine yourself working for their company when the CEO turns around and asks you “tell me a bit about yourself.” Would this catch you off guard or would you be able to give a clear and succinct description of who you are?  
jobsearcher.com/blog4 Ways to Make Your Job Posting More InclusiveAccording to a Glassdoor survey,
jobsearcher.com/blogHow to Calculate Net IncomeUnderstanding your finances can be daunting even if you’re good with numbers. Your net income, in particular, is a key metric for determining how well you’re doing financially and whether your current way of operating is sustainable or not.
jobsearcher.com/blogTo ATS or not to ATSAs hiring is becoming more analytical and data-driven, companies have found ways to incorporate technology to help hire and recruit more efficiently. ATS, also known as an applicant tracking system, has become one of the most widely adopted technological recruiting tools to date. In fact, according to data from Capterra: