Clinical Quality Improvement Specialist, Registered Nurse (Onsite 4 Days/Week)

Overview Leads interdepartmental Quality Improvement (QI) initiatives focused on promoting high-quality, safe, and equitable member care. Serves as a clinical and operational resource to QI committees, workgroups, and leadership. Analyzes outcomes, HEDIS/CAHPS/Stars performance, and trend data to identify opportunities for improvement in care coordination, quality, and member experience. Designs, implements, and evaluates QI programs aligned with DOH, CMS, and NCQA standards. Collaborates across departments—including Care Management, Utilization Management, Provider Relations, Compliance, and Analytics—to sustain continuous improvement, advance health equity, and ensure regulatory readiness. What We Provide Referral bonus opportunities Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability Employer-matched retirement saving funds Personal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Generous tuition reimbursement for qualifying degrees Opportunities for professional growth and career advancement Internal mobility and CEU credits What You Will Do Conduct clinical assessment including medication reconciliations, post-discharge transitions of care assessment and follow-up post emergency department assessment Collaborate across departments to ensure compliance with DOH, CMS, and NCQA requirements. Coach teams in applying continuous improvement methodologies (PDSA, LEAN, RCA) to achieve strategic objectives and national benchmarks for quality, satisfaction, and cost. Partner with analytics and program teams to identify trends and address performance gaps. Perform clinical reviews with network providers to validate diagnoses, address care gaps, and support accurate HEDIS/QARR documentation. Collaborate with providers to improve adherence to evidence-based care and quality measures. Lead and participate in multidisciplinary QI teams and committees to design, implement, and evaluate improvement initiatives related to clinical performance, documentation, and regulatory compliance. Support development of annual QI work plan, program evaluation, and performance reporting. Support value-based programs through data review, gap identification, and provider feedback. Perform medical record audits to evaluate adherence to documentation, coding, and quality standards. Provide education, feedback, and guidance to PCPs on VNS Health Medical Record Documentation Standards. Conduct audits of patient care records to monitor care quality and documentation accuracy. Develop forms, record abstracts, reports, and other tools for concurrent and retrospective patient care review, including design, testing and evaluation of the review methodology. Perform utilization and quality assessment reviews to maintain compliance with Federal and State regulatory requirements. Identify & analyze results to inform the development of correction plans. Collaborate with management to develop measurable action plans based on root-cause analysis, outcome trends, and survey results (HEDIS, CAHPS, Stars). Present recommendations to QI committees and leadership to drive improvement and accountability. Participate in the preparation for and assist with site visits of external providers for the purpose of regulatory quality compliance. Develop and disseminate training materials, clinical guidelines, and quality protocols to promote consistent evidence-based care across provider networks and internal teams. Provide education sessions and quality coaching as needed. Conduct follow-up reviews and reassessments to ensure corrective actions for regulatory findings, complaints, or incidents are implemented effectively and sustained over time. Document progress and escalates unresolved issues as appropriate. Develop, maintain, and update QI policies and procedures aligned with evolving regulatory and industry standards. Collaborate with analytics to collect, interpret, and share performance data with internal teams to drive transparency and accountability. Participate in special projects and perform other duties as assigned. Qualifications License and current registration to practice as a Registered Professional Nurse in New York State or New Jersey required Bachelor's Degree Nursing required Minimum of three years experience in a health plan or health care setting required Minimum of three years quality improvement experience preferred Minimum of one year experience in quality management, practice improvement and compliance preferred Demonstrated experience leading or facilitating cross‑functional quality initiatives preferred Excellent oral, written and interpersonal communication skills, including group facilitation skills required Knowledge of basic Performance Improvement tools and methodologies (e.g., PDSA, LEAN, Six Sigma) preferred Pay Range USD $85,000.00 - USD $106,300.00 /Yr. #J-18808-Ljbffr VNS Health