RN Quality Care Coordinator

Network Health is hiring an RN Quality Care Coordinator to develop and monitor quality interventions and close care gaps. The role engages members and providers, reviews medical records, coordinates clinical strategies, and ensures compliance with OCI, CMS, and NCQA quality requirements.

Responsibilities

• Provide direct outreach to members and/or providers in order to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars and NCQA
• Create written materials for members, physicians, and other customers in formats such as newsletters, brochures, self-care materials, educational handouts, letters and telephone scripts
• Responsible for development and coordination of member centric programs in alignment with industry and regulatory standards
• Evaluate utilization patterns, medical records and other metrics to monitor quality and efficiency results
• Provide clinical support for the appeals and grievance department and quality of care complaint process, preparing cases for medical director review when needed
• Identify opportunities for improvement and implement clinical interventions
• Prepare and/or deliver presentations for Quality Management committee, clinic or provider education, and system-wide committees as needed
• Coordinate, monitor, and document quality interventions and care management programs with goal of effectiveness that promotes value added care and service
• Collaborate closely with secondary providers (Breathe at Ease, Home Telemetry, Diabetes programs) to coordinate services for members
• Function as a liaison when needed for family, member and provider to communicate any current of potential issues
• Develop review and revise department policies and procedures including preventive services requirements
• Provide recommendations for preventive services medicine and evidence based clinical guidelines, seek approval and monitor for updates or relevant changes as assigned
• Research, submit and evaluate quality improvement projects regulated by CMS as assigned
• Implement systems of care that facilitate close monitoring of members to promote early intervention
• Assist with updating and maintaining Clinical Integration (CI) manual and documentation related to CI including reports

Preferred

• Bachelor of Science in Nursing, preferred
• Experience in basic data analysis, quality improvement, or HEDIS medical record review, preventive care, or health plan experience preferred
• Bachelor of Science in Nursing
• Basic Data Analysis
• Quality Improvement
• HEDIS Medical Record Review
• Preventive Care
• Health Plan Experience

Benefits

• Eligible to work at your home office (reliable internet is required); candidates must reside in Wisconsin. Travel to the corporate office in Menasha is required occasionally, including on the first day.
• Opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood.

Company

• Health plans and Medicare Advantage coverage for Wisconsin residents
• Menasha, Wisconsin, USA
• https://networkhealth.com/
• Founded in 1982
• 501-1000 employees

Qualifications

• Associate Degree in Nursing, required
• Current registered nurse licensure in Wisconsin required
• Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required
• Bachelor of Science in Nursing, preferred
• Experience in basic data analysis, quality improvement, or HEDIS medical record review, preventive care, or health plan experience preferred

Required skills

• HEDIS Medical Record Review, Health Plan Experience, Preventive Care, Registered Nurse (RN) Licensure — Wisconsin

Preferred skills

• Bachelor of Science in Nursing, preferred

Experience

• 4+ years