RN Quality Care Coordinator

Quality Care CoordinatorThe Quality Care Coordinator develops, implements and provides ongoing monitoring of intervention plans and quality gap closure. The role goal is to reduce medical costs and improve quality ratings through member and/or provider engagement, internal quality process improvement work, and coordination of overall clinical intervention strategies. The Quality Care Coordinator conducts HEDIS and year-round medical record reviews and is responsible for ensuring that Network Health meets all OCI, CMS and NCQA quality requirements. Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha is required occasionally for the position, including on first day. Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through FridayJob Responsibilities:Provide direct outreach to members and/or providers in order to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars and NCQACreate written materials for members, physicians, and other customers in formats such as newsletters, brochures, self-care materials, educational handouts, letters and telephone scriptsResponsible for development and coordination of member centric programs in alignment with industry and regulatory standardsEvaluate utilization patterns, medical records and other metrics to monitor quality and efficiency resultsProvide clinical support for the appeals and grievance department and quality of care complaint process, preparing cases for medical director review when neededIdentify opportunities for improvement and implement clinical interventionsPrepare and/or deliver presentations for Quality Management committee, clinic or provider education, and system-wide committees as neededCoordinate, monitor, and document quality interventions and care management programs with goal of effectiveness that promotes value added care and serviceCollaborate closely with secondary providers (Breathe at Ease, Home Telemetry, Diabetes programs) to coordinate services for membersFunction as a liaison when needed for family, member and provider to communicate any current of potential issuesDevelop review and revise department policies and procedures including preventive services requirements. Provide recommendations for preventive services medicine and evidence based clinical guidelines, seek approval and monitor for updates or relevant changes as assignedResearch, submit and evaluate quality improvement projects regulated by CMS as assigned. Implement systems of care that facilitate close monitoring of members to promote early intervention. Assist with updating and maintaining Clinical Integration (CI) manual and documentation related to CI including reportsJob Requirements:Bachelor of Science in Nursing, preferredAssociate Degree in Nursing, requiredCurrent registered nurse licensure in Wisconsin requiredMinimum of four (4) years clinical health care experience as a Registered Nurse (RN) requiredExperience in basic data analysis, quality improvement, or HEDIS medical record review, preventive care, or health plan experience preferredNetwork Health is an Equal Opportunity Employer