Registered Nurse Reviewer Quality Improvement
Company: MetroPlus Health Plan
Location: New York
Posted on: August 7, 2022
Job Description:
Empower. Unite. Care.MetroPlusHealth is committed to empowering
New Yorkers by uniting communities through care. We believe that
Health care is a right, not a privilege. If you have compassion and
a collaborative spirit, work with us. You can come to work being
proud of what you do every day.About NYC Health +
HospitalsMetroPlusHealth 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,
MetroPlusHealth s network includes over 27,000 primary care
providers, specialists and participating clinics. For more than 30
years, MetroPlusHealth has been committed to building strong
relationships with its members and providers to enable New Yorkers
to live their healthiest life. Position OverviewThe 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 MetroPlusHealth 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
DOHand 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 evaluation 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:
- Statistically significant changes in rates/stratifications
- 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.Must have a minimum of 5-7
years experience in the health care field.Must be proficient in
Microsoft Word, PowerPoint, Excel, and Access.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.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.Experience with and proficient in data analysis. Working
knowledge of relational database and statistical analyses is a
plus.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.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.uperior 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 co-workers 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
- .Quality Improvement experience in a managed care environment
preferred.
- Current licensed RN or foreign medical graduate required.
- Six Sigma Yellow or Green Belt preferred.Professional
Competencies
Integrity and TrustCustomer
FocusFunctional/Technical skillsWritten/Oral Communication
Associated topics: care unit, domiciliary, hospice, infusion,
intensive, intensive care, nurse, psychiatric, recovery,
surgery
Keywords: MetroPlus Health Plan, New York , Registered Nurse Reviewer Quality Improvement, Healthcare , New York, New York
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