Clinical Quality RN - Pittsburgh, KS - Full-time / Part-time

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Position responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. Position responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse CPC 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 Registered Nurse CPC will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. Position responsible for direction and guidance on provider-focused, clinical quality improvement and management programs.   The 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, HEDIS, CMS, NCQA and other tools. Position reports to the Quality Leadership of the Health Plan.

Job Components:

• Front Facing Practice Level Leadership


• Targeted Quality Improvement


• Gaps in Care Closure


• Relationship Management, Internal and External


• Community Engagement and Interaction


• Provider and Practice Education, Quality Oriented Health Topics

Primary Responsibilities:

• Supports effective 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/State Specific quality measures 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 HEDIS/State 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 HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State 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


• Documents and refers providers' non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer


• Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications


• If required, supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection, or for other focus studies as directed by the Plan Quality Director


• 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


• May do additional duties as assigned

• Current unrestricted RN licensure required in the state of operation


• 5+ years clinical experience, or other relevant experience


• 2+ years of quality improvement experience, or other relevant experience


• Ability to make formal presentations within the context of their role


• Ability to use databases and prepare reports as needed


• Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint


• Problem solving skills


• Excellent verbal and written communication skills