Under the direct supervision of the Quality Improvement Clinical Manager, the Quality Improvement Nurse monitors member health outcomes through internal and external data collection to determine effectiveness in maintaining safe care environments that meet regulatory requirements and to ensure members are receiving care that meets evidence-based standards. QI Nurse is responsible for collecting quality related data and reviewing medical records for HEDIS abstraction and overreads, Potential Quality of Care issues (PQIs) determination, regulatory compliance, Facility Site Review (FSR) and Medical Record Review (MRR) evaluations, Physical Accessibility Reviews (PARs), quality improvement (QI) activities development, data tracking and trending, and outcomes reporting. The Quality Review Nurse must be able to keep accurate records, manage and analyze data, as well as respond appropriately and timely, both verbally and in writing to internal audiences, external professional staff and regulatory agencies.

Position overview

• Perform Facility Site Review and Physical Accessibility Reviews
• Uses state approved tools and conducts FSRs, MRRs, and PARs, using clinical knowledge and judgement to determine FSR and medical record compliance with regulatory requirements, documenting, reporting and communicating findings and results as required
• Issue Corrective Action Plans (CAP) as warranted, monitoring and document closing CAPs as appropriate
• Conduct pre-contractual reviews with potential contracted providers
• Assess and document compliance with Physical Accessibility standards
• Maintain thorough knowledge of the DHCS site review requirements and processes
• Assists with Healthcare Effectiveness Data and Information Set (HEDIS) Medical Record Review
• Ensures accurate collection, abstraction, over reading and reporting of HEDIS medical record data
• Ensures medical record reviews are within compliance of the National Committee for Quality Insurance (NCQA) HEDIS Specifications
• Ensures accurate translation of these medical record data elements to appropriate software or database system
• Conducts Quality Improvement Medical Record Review
• Investigate, determine and follow-up on Potential Quality Issues
• Develop, implement, and follow up with corrective action plans, giving technical assistance to provider as appropriate
• Educate providers and office staff about quality improvement activities, processes and corrective action interventions to facilitate their compliance with HPSM, federal, state, and NCQA regulations and standards
• Analyze, develop and implement improvement activities to increase compliance rates as measured by nationally standardized benchmarks and definitions
• Meet productivity, work quality and work product goals as set by management
• Perform computer-based statistical analysis of data related to the QI program and collect data from one or more sources including outpatient lab, claims and other data sources
• Create processes documentation for QI and/or HEDIS activities and collaborates with practices to integrate their electronic medical record data into HPSM systems
• Develop, implement, and follow up with corrective action plans, giving technical assistance to provider as appropriate

Requirements
These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply.

Education and experience:

• Associate degree in Nursing.
• Bachelor’s degree in nursing or a related health services field is a plus.
• Two (2+) plus years of relevant nursing experience in a managed care/quality improvement type of setting.

License and Certification:

• A valid California Registered Nurse license.
• DHCS Facility Site Reviewer Certification, Trainer or Master Trainer certification highly preferred.

Knowledge of:

• Knowledge of HEDIS reporting
• The concepts of managed health care
• Medicare and Medi-Cal and regulatory programs
• Quality improvement study design methods and appropriate quality improvement tools and applications is preferred
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint

Ability to:

• Works cooperatively with others
• Work as part of a team and support team decisions
• Communicate effectively, both verbally and in writing
• Adapt to changes in requirements/priorities for daily and specialized tasks
• Evaluate medical records and other health care data
• Plan, organize and lead data collection activities
• Resolve simple and/or complex analytical problems
• Present statistical and technical data in a clear and understandable manner utilizing appropriate visual aids
• Interact professionally and effectively with providers, physicians, and staff from all departments within and outside the Plan
• Establish and maintain effective and cooperative working relationship with HPSM staff and others contacted in the course of the work
• Maintain accurate records and confidentiality of sensitive medical information
• Assume responsibility and exercise good judgment in making decisions within the scope of authority of the position
• Accurately complete tasks within established times and to effectively prioritize multiple tasks and deadlines

Other:

• Must have own vehicle and valid driver’s license with proof of insurance in conformity with state law minimums and be willing to travel (primarily) in San Mateo County

Benefits

Excellent benefits package includes:

• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 12 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Tuition reimbursement plan
• Employee wellness program

It is HPSM's policy to provide equal employment opportunity for all applicants and employees. HPSM does not unlawfully discriminate based on race, religion, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, sexual orientation, veteran status, registered domestic partner status, genetic information, gender, gender identity, gender expression, or any other characteristic protected by applicable federal, state, or local law. HPSM also prohibits discrimination based on the perception that an applicant or employee has any of those characteristics or is associated with a person who has or is perceived to have any of those characteristics.