Quality of Care RN

Job Summary:
The Quality of-Care RN Interventions contributes to quality improvement functions and is an active contributor to the Plans implementation/enhancement of new and existing healthcare quality improvement initiatives and education programs. The Quality-of-Care RN-Interventions ensures maintenance of programs for members in accordance with prescribed quality standards; conducts member outreach activities, provides necessary education and guidance to close identified gaps in care, and maintains and ensures necessary reporting and monitoring for key intervention activities. The Quality-of-Care Interventions RN is a key part of the Quality Team working to improve HEDIS and Stars scores while improving the overall health of our members by providing education on clinically recommended preventative care, as well as coordination and support to assist the member in obtaining needed services.

Key Functions/Responsibilities:
Place outreach calls to members identified as having gap(s) in preventative care
Educate the member on importance of preventative care and screening
Follow up with members requiring support in taking steps to close care gaps
Evaluate Health Related Social Needs that may impact the member s ability to access needed services
Evaluate for ongoing care management needs and make referrals as indicated
Participate in Quality Workgroups focused on HEDIS, Stars, and other quality measures
Record member interactions in the clinical documentation system
Write narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions.
Meet quality and timeliness standards to achieve individual and departmental performance goals as defined within the department guidelines
Explain programs and results of programs, and document findings and limitations of department interventions.
Demonstrate and maintain current working knowledge of the required systems, procedures, forms, and manuals
Comply with all state and federal regulations for activities performed
As designated, facilitate quality improvement intervention activities meetings, and discussions with and between other departments within the organization
Surfaces to Manager and Director any gaps in processes that may require remediation.
Create and Maintain policies & standard operating procedures of processes to maintain compliance
Support programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.
Other duties as assigned

Supervision Exercised:
None

Supervision Received:
General direction received weekly from the Senior Manager Delegation and Quality Partnerships
Qualifications:

Education Required:
Associate s degree general field of study, or post high school nursing diploma

Education Preferred:
Bachelor's, Master s

Experience Required:
2 years of experience as practicing RN in hospital/healthcare setting.

Experience Preferred/Desirable:
2+ years of experience in health insurance field

Required Licensure, Certification or Conditions of Employment:
Successful completion of pre-employment background check
Active, current, and unrestricted license to practice in the state of Massachusetts as a registration

Job Skills
Required
Strong proficiency in use of office equipment including copier, fax machine, scanner, and telephones
Strong PC proficiency in word processing, spreadsheet, and database software
Preferred
Advanced PC proficiency

Professional Competencies
Required
Effective collaborative and proven process improvement skills
Strong oral and written communication skills; ability to interact within all levels of the organization
Demonstrated commitment to excellent customer service
Knowledge and understanding of current trends in healthcare
Aptitude for aligning process, projects, and people to meet business goals in cross-functional team settings
Health care payer business knowledge including processes and operational data and functions that support the business
Maintain confidentiality and privacy
Capable of investigative and analytical research to make decisions and recommendations based on available information
Independent and sound judgment with good critical thinking skills
Knowledge of managed care, utilization management, and quality management
Establish and maintain working relationships with health care providers, members, and coworkers
Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards
Ability to Interpret policies, programs, and guidelines
Establish and maintain working relationships in a collaborative team environment
Organizational skills with the ability to prioritize tasks and work with multiple priorities
Maintains current knowledge of State, Federal and other applicable regulatory/accrediting agency requirements as they apply to department functions

Required Leadership Experience and Competencies
Ability to use available information to focus project's Product and identify priorities
Ability to coordinate/lead small projects
Represent WellSense in the community

Working Conditions and Physical Effort:
Regular and reliable attendance is an essential function of the position.

License: RN (Mass)