Quality Reviewer, Advanced Practice Clinician

• 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, generous tuition reimbursement, CEU credits, and advancement opportunities

• Collaborates with clinical management to identify, develop and implement quality improvement standards and criteria that meet program goals. Evaluates effectiveness of standards and recommends changes, as needed.
• Conducts audits of patient/member records. Audited records include in-home assessments for Annual Wellness and Palliative Care, for claims/encounters from providers, to ensure documentation and coding accuracy. Perform Risk Adjustment data validation for Medicare HCC Risks and CPT codes for billing
• Performs medical record reviews for HEDIS or other related compliance or quality improvement initiatives.
• Ensures 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.
• Coaches and facilitates performance improvement activities designed to help the teams and programs meet and exceed quality scorecard indicators. Instructs staff in the meaning and use of data for the purpose of assessing and improving quality.
• Participates in the development of standards and criteria with Federal and State regulatory requirements and performance standards of care. Participates in the development of performance measures and data collection instruments.
• Assists to educate clinical staff to correct identified opportunities for improvement in health status and outcomes.
• Collaborates with operations management in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys, and studies.
• Supports and guides comprehensive, advanced nursing care guidance to clinical staff, including physical examination, comprehensive history, screening for physical and/or psychological conditions, emergent interventions, pharmacological and non-pharmacological interventions, ordering treatments and DME, preventative health maintenance activities, care management, referrals, discharge planning, counseling, and patient education.
• Provides, and ensures advanced practice nursing care for patients in accordance with current State and Federal rules and regulations for Nurse Practitioner scope of practice and national standards of care, which includes, medical assessments and other assessments and interventions as needed.
• Collaborates with Education department in the development of and implementation of quality related training programs.
• Keeps informed of the latest internal and external issues and trends in utilization and quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies, and procedures to address these trends. * Participates in developing and implementing quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, Quality Scorecard, IPRO Projects, and CMS Quality Projects.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:
Licensed and current registration to practice as a Nurse Practitioner or Physician Assistant required

Education:
Master's Degree in Nursing or Physician Assistant with certification required

Work Experience:
Minimum of four years clinical experience as a Nurse Practitioner or Physician Assistant utilizing full scope of practice required 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