Quality Improvement Nurse - Part Time

Job Description

Job Description

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The Company:

AlohaCare is a local, non-profit health plan serving Hawai`i’s low-income residents with free Medicaid and dual Medicare health insurance coverage. Our members include children, seniors and adults residing on all islands. We provide comprehensive benefits and managed care services with an emphasis on healthy living habits and preventive primary health care. Our approach is to meet the whole-person health and social needs of members. Through our community partnerships we offer innovative services such as connection to social service agencies, Native Hawaiian healing services and in-home primary care for qualified members. Our mission is to serve in the true spirit of aloha by ensuring and advocating for access to quality health care for all. We are Hawaii’s third-largest health plan and offer a wide network of quality primary care, specialists, hospitals, pharmacies and among many other providers across the state.

The Culture:

AlohaCare employees have a passion for helping Hawai`i’s most underserved communities. Our caring culture is fundamental to our company-wide team approach to providing high-quality services. We support our employees with a supportive and positive work environment, healthy work-life balance, continuous communication, and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

The Opportunity:

The Quality Improvement Nurse supports AlohaCare’s quality strategy by working directly with providers, members, and internal teams to improve quality outcomes and close gaps in care. This role performs provider and member outreach, coordinates interventions for targeted quality measures, supports HEDIS, Medicare Stars, Med-QUEST Pay for Performance, population health, and other quality improvement initiatives, and helps ensure that members receive timely preventive, chronic condition, and follow-up care.

The Quality Improvement Nurse serves as a clinical resource for quality measure improvement activities, including outreach to members and providers, review of clinical information, coordination of services, education on care gap closure opportunities, and documentation of outreach outcomes. This position requires strong clinical judgment, communication skills, and the ability to work collaboratively across departments to improve member outcomes, quality scores, and regulatory performance.

Primary Duties and Responsibilities:

• Conducts telephonic and/or written outreach to members, providers, provider offices, facilities, pharmacies, and community partners to support closure of gaps in care.
• Coordinates with providers and members to address targeted quality measures, including but not limited to:
  • Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
  • Diabetes Care – Blood Sugar Controlled
  • Diabetes Care – Eye Exam
  • Kidney Health Evaluation for Patients with Diabetes
  • Controlling High Blood Pressure
  • Breast Cancer Screening
  • Colorectal Cancer Screening
  • Plan All-Cause Readmissions
  • Follow-Up After Hospitalization for Mental Illness
  • Prenatal and Postpartum Care
  • Well-Child Visits in the First 30 Months of Life
  • Child and Adolescent Well-Care Visits
  • Childhood Immunization Status
• Reviews member gap-in-care reports, clinical data, claims, supplemental data, and other available information to identify outreach priorities and intervention opportunities.
• Works with provider offices to support scheduling, documentation, medical record submission, supplemental data capture, and other activities needed to close quality gaps.
• Educates members on the importance of preventive care, chronic condition monitoring, follow-up care, and available health plan or community resources.
• Assists members in navigating care needs, including follow-up appointments, screenings, testing, immunizations, and services related to targeted quality measures.
• Collaborates with internal departments, including Quality Reporting, Population Health Management, Health Services, Pharmacy, Provider Relations, Grievance and Appeals, Compliance, and other teams to support quality improvement initiatives.
• Supports development and implementation of member- and provider-facing interventions aimed at improving HEDIS, Medicare Stars, Med-QUEST P4P, CAHPS, HOS, and other quality outcomes.
• Tracks outreach activities, member/provider responses, barriers to care, and gap closure outcomes in applicable systems, reports, and project trackers.
• Identifies barriers impacting gap closure, such as access to care, transportation, member engagement, provider documentation, or data limitations, and escalates trends to Quality leadership.
• Assists with provider education related to quality measure requirements, documentation expectations, coding considerations, supplemental data, and medical record submission.
• Supports medical record review, audit preparation, supplemental data collection, and validation activities related to quality reporting.
• Participates in quality improvement projects, performance improvement initiatives, committees, workgroups, and provider/member engagement campaigns.
• Prepares updates, reports, and summaries on outreach progress, quality measure performance, barriers, interventions, and opportunities for improvement.
• Assists with policies, procedures, desk-level procedures, workflows, scripts, training materials, and member/provider communications related to quality improvement and gaps in care.
• Supports compliance with NCQA, CMS, Med-QUEST, state, federal, and other regulatory or accreditation requirements related to quality improvement activities.
• Identifies and refers potential quality of care concerns, member grievances, suspected fraud, waste, or abuse, and other issues to the appropriate department.
• Maintains confidentiality of all members, provider, and Plan information in accordance with AlohaCare policies and applicable state and federal laws.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

• Associate’s degree in nursing or related field or equivalent combination of education and experience.

• Licensed RN in the State of Hawaii
• Minimum of 2 years of clinical experience.
• Demonstrates ability for assessment, evaluation and interpretation of clinical information.
• Familiarity with healthcare regulations and accreditation standards.

• Achieves results, builds trust, communicate effectively, customer and quality focused.
• Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization.
• Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
• Knowledge of preventive care, chronic condition management, quality improvement principles, and managed care operations.
• Familiarity with HEDIS, Medicare Stars, Med-QUEST Pay for Performance, NCQA accreditation, CMS requirements, or other quality reporting programs preferred.
• Ability to conduct professional member and provider outreach using strong telephonic, written, and interpersonal communication skills.
• Professional telephonic etiquette skills.
• Ability to solve problems, analyze, think critically and make good judgment.
• Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.

• Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.

• Basic computer knowledge, data analysis and competence with spreadsheet and database programs
• Working knowledge of Microsoft programs: Word, Excel, Outlook and PowerPoint.
• Experience in the operation of general office equipment to include PC, fax/copy machine and phone system.

Preferred Requirements:

• Minimum of 3 years of clinical experience; experience in an acute care setting desirable.
• Knowledge of QI/QA principles and methodology, health care/social research methodology, and ICD-9, ICD-10 and CPT codes desirable.
• Knowledge of HEDIS technical specifications, Medicare Stars, Med-QUEST P4P, CAHPS, HOS, NCQA, CMS, and/or other quality measure programs.
• Experience with provider outreach, member outreach, medical record review, supplemental data collection, or gaps-in-care closure initiatives.
• Knowledge of diabetes, hypertension, behavioral health follow-up, maternal/child health, preventive screenings, immunizations, and chronic disease management.
• Coding knowledge, CPC, CRC, Certified Diabetes Care and Education Specialist, or other relevant certification preferred.
• Previous experience in a managed care environment.

Mental, Physical and Environmental Demands:

• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
• In office working environment.
• May require prolonged sitting - up to 4 hours.
• Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.
• Requires frequent travel throughout the state of Hawaii, including on Oahu and Neighbor Islands to conduct quality reviews or provider training. Own transportation is necessary to meet off-site travel requirements.

Salary Range: $78,000 - $85,000 annually

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.