Senior Specialist, National Quality Improvement (RN) - Remote
RemoteUnited States
Job Summary
Lead quality improvement initiatives by guiding departmental professionals, managing near real-time clinical interventions, and ensuring accurate completion of federal and state compliance activities. Conduct medical record reviews for HEDIS and NCQA audits, collect data from provider offices, and compare documentation against regulatory specifications to determine service accuracy. Prepare narrative reports interpreting regulatory findings, present results to leadership, and coordinate with vendors and auditors on medical record collection processes. Raise process gaps requiring remediation and assist with physician and member interventions while supporting accreditation activities.
Required Qualifications
- At least 3 years experience in health care
- minimum of 2 years experience supporting quality improvement initiatives
- experience preferably in a managed care setting
- equivalent combination of relevant education and experience
- Registered Nurse (RN)
- License must be active and unrestricted in state of practice
- Quality auditing experience
- peer review experience
- process improvement experience
- Knowledge of Healthcare Effectiveness Data Information Set (HEDIS)
- Knowledge of National Committee for Quality Assurance (NCQA)
- Strong attention to detail
- critical-thinking skills
- problem solving skills
- Ability to work cross-collaboratively in a highly matrixed organization
- Time-management skills
- ability to multi-task
- Excellent verbal and written communication skills
- Microsoft Office suite/applicable software program(s) proficiency
Desired Qualifications
- Certified Professional in Health Quality (CPHQ)
- Certified HEDIS Compliance Auditor (CHCA)
- Registered Health Information Technician (RHIT)
- training in coding procedures
- Certified Professional Coder (CPC)
- Medical coding experience
- Medical record abstraction experience
- Managed care experience
- Ability to work across all levels of the organization, including working with executive audiences, vendors, providers, and the government as a customer
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.