Job Title: Registered Nurse - Quality Improvement - Government Programs
Job Number: 000FMX
- Participates in clinical quality improvement programs and committees, performs follow up as necessary.
- Educates clinical staff on quality processes, regulations and corrective actions indentified by the department of quality committees.
- Ensures compliance with policies and procedures.
- Supports clinical departments with developing and implementing necessary teams, tools and care process changes in parallel with physician practices efforts to improve patient/member outcomes.
- Participates in analysis of network aggregate results of existing clinical outcome measures. Collaborates with health plan senior staff and informatics resources to develop, monitor and analyze performance measures.
- Ensures compliance with all state and federal regulations and guidelines.
- Manages the appeal and grievance process for government health plan lines of business.
- Ensures documentation of all findings and actions taken as a result of a grievance or appeal.
- Collaborates with Compliance to integrate state and federal law changes related to grievances and appeals into the Plan’s regulatory system.
- Performs review of patient medical records for monitoring and evaluation of quality and appropriateness of care.
- Performs other related duties, as required.
- Bachelor's Degree in Nursing, required.
- Current license to practice as a Registered Professional Nurse in New York State.
- Minimum of five (5) years of nursing experience, required.
- Knowledge of Healthcare Effectiveness Data and Information Set (HEDIS), Quality Assurance reporting Requirements (QARR), National Committee for Quality Assurance (NCQA) and NY State laws regarding healthcare marketplace and government insurance programs.
Job Quality Management
Primary Location Nassau County-Greenvale-2200 Northern Boulevard
Schedule Part Time
Shift Day Job