Clinical Outcomes Quality Lead Nurse - 240519  

DESCRIPTION/RESPONSIBILITIES: The Clinical Outcomes Quality Lead RN position will be responsible for ongoing management of the HEDIS project.  The Clinical Research Lead Nurse will oversee all aspects of the day to day operations of the HEDIS project during HEDIS season, as well as NCQA accreditation projects. The Clinical Research Lead Nurse will focus on tasks that occur in accordance with HEDIS, CMS or other requirements as applicable. Position reports to the Manager of Quality Analytics.

This position does require travel to provider offices in the Philadelphia 5-county region as well as parts of Northern Delaware.

Primary Responsibilities:  * Serves as subject matter expert (SME) for HEDIS/STARs Hybrid Measures.  * Prepares clinical training materials and conducts virtual/onsite training for full-time and contract staff.  * Serves as liaison with key vendors (mainly copy companies such as CIOX) supporting HEDIS/STARs Measures.  * Reports individual member quality of care trends of concern to the Manager of Quality Analytics, Quality Director and or Plan Medical Directors.  * Coordinates clinical evaluations through medical record audits to determine compliance with quality metrics, compliance with service delivery and quality standards.  * Works closely with the director, manager and auditor to document compliance discrepancies for HEDIS measures in accordance with the NCQA specifications.  * 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.  * Documents and refers providers' non-clinical/service issues to the appropriate internal parties.  * Works with providers on established clinical practice guidelines (HEDIS), and appropriate documentation consistent with state specific measures and technical specifications.

Job Requirements Required Qualifications:  * Current unrestricted RN licensure but will consider LPN candidates with applicable experience  * 5+ years clinical experience  * 2+ years of quality improvement experience  * Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint  * Ability to travel to provider sites up to 50% within the Philadelphia 5 county area and north Delaware

Preferred Qualifications:  * Experience working in Medicaid and/or Medicare  * Health care and insurance industry experience, including regulatory and compliance  * Knowledge of one or more of the following: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry  * Strong leadership skills with ability to multi-task and think independently

Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity