RN Clinical Quality Assurance Auditor

Overview Are you an experienced RN with a strong background in Quality including quality of care reviews, incident investigation, and regulatory compliance? VNS Health Plans is seeking a seasoned clinical professional to play a critical role in reviewing and resolving major incidents and serious adverse events in a hybrid work environment. In this role, you will lead end‑to‑end case investigations, ensuring adherence to regulatory requirements while identifying root causes and driving corrective actions. You'll collaborate across clinical, operational, and compliance teams to not only resolve cases, but also strengthen processes, reduce recurrence, and improve overall quality performance. This is an opportunity to apply your clinical expertise beyond bedside care, leveraging your knowledge to influence system‑wide improvements, enhance compliance, and protect member safety at scale, while benefiting from the flexibility of a hybrid role. 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, CEU credits and advancement opportunities What You Will Do Collaborate with clinical management to identify, develop and implement quality improvement standards and criteria that meet program goals. Evaluate effectiveness of standards and recommend changes, as needed. Ensure Quality Improvement programs are aligned with CMS Triple Aim framework: improving the patient's experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare. Establish and communicate protocols and standards of care for a culturally and demographically diverse patient/member population; provide intervention guidelines based on these population health needs. Coach and facilitate performance improvement activities designed to help teams and programs meet and exceed quality scorecard indicators. Instruct management and staff in the meaning and use of data for assessing and improving quality. Participate in the development of standards and criteria for monitoring compliance with Federal and State regulatory requirements and VNS Health Plans performance standards of care. Develop performance measures and data collection instruments. Facilitate quality assurance and utilization review activities with interdisciplinary teams on ways to improve and positively affect the care that is provided to patients/members. Review and analyze changes in the health status and outcomes of patients/members utilizing outcomes data. Consult and collaborate with clinical staff to identify trends and opportunities for improvement in health status and outcomes. Collaborate with operations management in the development of action plans based on quality reviews and root cause analysis findings. Make recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies. Conduct audits of patient/member case records. Develop forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology. Collaborate with operations management to assure compliance with CMS and DOH requirements. Coach, facilitate and monitor continuous improvement to attain strategic quality objectives and industry benchmarks for patient/member outcomes, satisfaction, cost and regulatory requirements. Collaborate with Education department in the development of and implementation of quality related training programs. Keep informed of the latest internal and external issues and trends in utilization and quality management through committee participation, networking, professional memberships in related organizations, attending conferences/seminars and reading select journals. Revise or develop processes, policies and procedures to address these trends. Perform onsite medical record reviews for HEDIS or other related compliance or quality improvement initiatives. Participate in the development and implementation of quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, Quality Scorecard, IPRO Projects, and CMS Quality Projects. For RN Quality Reviewer only: Provide clinical support in the Grievance and Appeals process. Follow up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively. Investigate patient/member related complaints and quality of care (QOC) issues, incidents, and serious adverse reportable events in collaboration with internal staff and providers. Perform utilization and quality assessment review; identify and analyze results; prepare investigation summary report; and create or implement corrective action plan as appropriate. Provide education about identified quality trends, outcomes of reviews and new requirements. Qualifications Licenses and Certifications: License and current registration to practice as a registered professional nurse preferably in New York State required. Education: Bachelor's Degree in healthcare administration, human services or business administration or related discipline or the equivalent work experience in a related professional field required. Work Experience: Minimum of four years clinical experience in a health care setting, including at least two years with a focus on quality improvement and measurement or related experience required. Knowledge of health care delivery systems, patient care, care coordination, and clinical processes required. Ability to perform statistical/quantitative analysis required. Excellent oral, written and interpersonal communication skills required. Knowledge of basic Performance Improvement tools and methodologies preferred. Pay Range USD $93,400.00 - USD $116,800.00 /Yr. #J-18808-Ljbffr VNS Health