Clinical Quality RN Resume Samples

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Queenie
Effertz
83361 Tobin Plain
Chicago
IL
+1 (555) 479 5226
83361 Tobin Plain
Chicago
IL
Phone
p +1 (555) 479 5226
Experience Experience
Houston, TX
Clinical Quality RN
Houston, TX
Greenholt-Upton
Houston, TX
Clinical Quality RN
  • Serves as subject matter expert (SME) for assigned HEDIS / State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS / State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates
  • Serve as liaison with community health care facilities and the state of Michigan in large performance improvement projects related to respiratory health conditions
  • Develop policies, procedures and work flows
  • Project leader for Network Management and working with Physician Offices
  • There is an opportunity to work-at-home after the initial training. There are no weekends, nights, on - call or holiday work.
  • Educate primary care practitioners on clinical and preventive health guidelines, primary care operations best practices, documentation standards and coding for outcome reporting
  • Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation
New York, NY
Senior Clinical Quality Rn-telecommuter
New York, NY
Lesch LLC
New York, NY
Senior Clinical Quality Rn-telecommuter
  • This is a telecommuter, work from home position; Candidate should live Trumbull or Ashtabula or surround Country including Lake Geauga, Portage, Mahoning
  • Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases, and researching to identify members' encounter history
  • Participates, coordinates, and / or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
  • Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care
  • Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Manager and Quality Director
  • Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
  • Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
present
Philadelphia, PA
VP Clinical Quality, RN Hedis / Stars
Philadelphia, PA
Kilback and Sons
present
Philadelphia, PA
VP Clinical Quality, RN Hedis / Stars
present
  • Plans, organizes, directs the administration of all WellMed Quality Programs
  • Leads projects with cross-functional teams and senior leaders across medical, nursing, clinical functional areas to achieve targeted clinical strategic performance goals
  • Provides long-term planning and oversight to ensure quality improvement is integrated into strategic direction and operations as well as the mission and values of the company
  • Collaborates with physicians to execute the implementation of the clinical quality data initiatives
  • Provides expertise to the training department on HEDIS and STAR measures and tools that support collection of and communication about HEDIS and STAR to the enterprise
  • Develops HEDIS, STAR member and provider engagement strategies
  • Collaborates with WellMed and Optum executive teams to execute HEDIS and STAR strategies
Education Education
Bachelor’s Degree in Healthcare
Bachelor’s Degree in Healthcare
Tulane University
Bachelor’s Degree in Healthcare
Skills Skills
  • This is an office position located in Downtown Phoenix at 1 East Washington Street
  • Perform clinical documentation review of inpatient and outpatient care delivered to adults, children with Medicaid, Medicare health care benefits through United Health Care Community Plans in Arizona for peer review and internal investigations of Quality of Care concerns
  • Create professionally written case summaries for Peer Review, and create written letters to regulatory agencies
  • Presenting cases before a provider advisory committee, peer review in conjunction with the reviewing Medical Director
  • Reviewing plans of correction from providers in response to a substantiated QOC or CI occurrence
  • Taking actions to report CI or other applicable occurrences according to State and Federal guidelines and UnitedHealthcare policy and procedure
  • Effectively interface with internal and external customers, facilities and providers to resolve quality of care concerns, obtain medical records and information
  • Conducting delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare. This includes reviewing samples of contractor work against an audit tool or information found in medical charts
  • Performing on-site audits of residential care facilities such as assisted living facilities or practitioner offices
  • Assisting in the development of oversight tools and processes for clinical quality assessment
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15 Clinical Quality RN resume templates

1

Senior Clinical Quality Rn-telecommuter Resume Examples & Samples

  • *This is a telecommuter, work from home position; Candidate should live Trumbull or Ashtabula or surround Country including Lake Geauga, Portage, Mahoning***
  • Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Manager and Quality Director
  • Current unrestricted RN license in the state of Ohio
  • 1 year of Medicare experience
  • 2 year of Medicaid experience
  • Knowledge & demonstrated experience with continuous Quality Improvement concepts and tools i.e. audits, chart review, knowledge of current CPT and ICD10 coding
  • Demonstrated presentation and communications skills with clinicians and organizational leaders
  • Ability to work with and relate to staff and demonstrate active listening skills
  • Display professionalism and respect cultural differences
  • Intermediate computer literate and have MS Word, Excel, Outlook, and Internet demonstrated skills
  • Ability to foster teamwork with all levels of management and staff within highly matrix organization
  • 2 years of HEDIS
  • Knowledge of CMS guideline
2

Clinical Quality RN Auditor Resume Examples & Samples

  • Independently use discretion and judgment to evaluate objective and subjective clinical documentation of member records and engagements to assess performance of nursing skill and the skills of other allied health professionals, based on Business Unit expectations for performance
  • Consults with Medical Directors to calibrate on subjective assessments to ensure consistency of feedback related to complex, high risk cases
  • Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow Optum's/Alere Healths policies, State regulations and Accreditation standards
  • Generate reports /findings of reviews for the Clinical Management Teams: in a clear, concise manner that is understandable and actionable
  • Provide consultation with Clinical Management leaders as requested to support staff coaching and development efforts
  • Assist the Clinical Management team, as needed, to determine areas that require immediate remediation and assist Optum’s employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and consumer engagement
  • Identifies tracks and records best practices, sharing the specifics with team leadership
  • Participate in training and performance improvement related projects to support staff development as well as assist with the training of new Call Quality employees
  • The Clinical Quality RN will highlight key findings for implementation of performance improvement plans when necessary
  • Work with colleagues across business units to ensure that process and procedural changes are reflected in staff member’s documentation such as job aids and policies
  • Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings
  • Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings
  • Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served
  • Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner
  • Ability to work and interact with professionals as part of an interdisciplinary team
  • Able to work independently; self-motivated with good organizational skills
  • Quickly learn and adapt to new technology
  • RN required in the state that you reside (must be active and unrestricted)
  • NICU or Maternal Case Management
  • Capable to apply and conduct a logical approach to audits to arrive at fact-based recommendations based on source of truth documentation
  • Ability to remain a neutral party, negotiate, and drive to expected result
  • Has a passion for quality and performance improvement
  • Specialty license and experience preferred in Case Management
  • 2 or more years of clinical audit experience preferred
  • Bi-lingual Skills Desired
3

VP Clinical Quality, RN Hedis / Stars Resume Examples & Samples

  • Plans, organizes, directs the administration of all WellMed Quality Programs
  • Collaborates with leaders to meet operational program needs, ensures compliance with state/federal health plan requirements, Medicare guidelines, NCQA and health plan requirements
  • Leads projects with cross-functional teams and senior leaders across medical, nursing, clinical functional areas to achieve targeted clinical strategic performance goals
  • Provides long-term planning and oversight to ensure quality improvement is integrated into strategic direction and operations as well as the mission and values of the company
  • Develops and maintains policies and procedures that support the corporate initiatives that meet State, Federal legal requirements and standards
  • Collaborates with physicians to execute the implementation of the clinical quality data initiatives
  • Provides expertise to the training department on HEDIS and STAR measures and tools that support collection of and communication about HEDIS and STAR to the enterprise
  • Develops HEDIS, STAR member and provider engagement strategies
  • Collaborates with WellMed and Optum executive teams to execute HEDIS and STAR strategies
  • Facilitates, integrates, and/or coordinates the implementation and evaluation of identified quality improvement, HEDIS and STAR activities as requested
  • Participates in requested evaluations and audits for health plans
  • Coordinates reporting on quality initiatives to all appropriate committees
  • Maintains QI program documents, reports, and committee minutes and follows all internal privacy and confidentiality policies and procedures
  • Oversees HEDIS data submission process to all contracted health plans
  • Leads accreditation efforts as defined by enterprise
  • Oversees medical/nursing/clinical workflow mapping, performance monitoring, and coaching site visits in clinic settings using process improvement methodologies to identify workflow
  • Gaps and establish future-state recommendations
  • Directs and promotes clinical support for clinic staff and nursing roles (RN or LVN Health Coach) with subject matter expertise and resources for population management, nurse advocacy and development opportunities, and nurse coaching/feedback programs
  • · ·
  • Master’s degree in Healthcare or Business Administration required (8 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a Master’s degree)
  • Active and unrestricted Registered Nurse license in the US with the ability to obtain a Texas license within 12 months of starting employment
  • Fifteen or more years of management-level experience in managed care, medical management programs required, including five or more years of experience at the Director level or above Knowledge of the business environment and business requirements (e.g., strategy changes, emerging business needs)
  • HEDIS/STARS expertise
  • Excellent verbal, written communication, presentation, and facilitation skills Knowledge of fiscal management and human resource management techniques
  • Ability and willingness to travel both locally and non-locally as determined by business need
4

Senior Clinical Quality Rn-hedis Resume Examples & Samples

  • Perform HEDIS medical record review in physician offices throughout the state of Nevada
  • Complete inter-rater reliability testing and required computer training successfully in order to complete this data collection
  • Conduct additional QI audits through medical record review
  • Help with credentialing activities for organizations and facilities such as hospitals and skilled nursing facilities
  • Educates Physicians, RNs and other clinical employees in the off season
  • 2+ years Clinical Quality experience
  • Previous experience educating Physicians, RNs or other clinical and/or non-clinical employees
  • Must be self-motivated and able to learn new computer software quickly
  • Must be comfortable and proficient in being trained on a data collection software that allows the person to collect and record medical record information accurately on a timely basis
  • Ability to demonstrate knowledge and to apply to job functions, those state and federal laws and regulations applicable to the operation unit
  • Previous HEDIS data collection and medical record / chart review experience highly
  • Medical Record Audit Experience a Plus (medical record review and capturing/documenting appropriate clinical information needed to assure compliance)
  • 2+ years Clinical Quality experience in acute care or managed care setting
5

Clinical Quality RN Resume Examples & Samples

  • Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation
  • Conducts clinical quality audits (CMS Regulations, State Regulations, File and Chart reviews, etc.) and may also be responsible for NCQA, URAC and Joint Commission audit requirements
  • Responsible for the reporting and analysis of member care quality and for the development of plans and programs to support continuous quality improvement using Microsoft Office Suite or Access
  • Analyzes and investigates
  • Responsible for Policy and Procedure Quality and Review
  • Training on and presenting new processes
  • Attend, participate and present at Committees as required
  • Project leader for Network Management and working with Physician Offices
  • Experience with Medicare/Medicaid, ACO, Stars and HEDIS
  • Ability to Multitask
  • RN license in AZ
  • 3 years of experience in a clinical setting
  • 3 years of QA experience
  • MS Office advanced proficiency is a must
  • Ability to travel to providers in Maricopa County and trips outside of Maricopa County as required - 20% to conduct audits and review charts, etc
  • Strong background in Quality Improvement / Management
  • Certifications in Quality Improvement / Management (Greenbelt, Lean, etc
  • CTQ
  • Clinical Database
6

Senior Clinical Quality RN Resume Examples & Samples

  • Current unrestricted RN licensure in New Mexico
  • 1+ yrs of experience of Medicare/Medicaid regulations
  • 2+ yrs of clinical experience as an RN
  • 1+ yrs analytical and problem solving skills while managing multiple tasks simultaneously
  • Proficient in Microsoft Office, Word, and Excel
  • Knowledge of CMS Hospital Acquired Conditions and Never Events
  • The applicant should possess a high attention to detail, exceptional documentation abilities, and organizational skills
  • Proven ability to meet critical deadlines consistently, while completing tasks accurately
7

Clinical Quality RN Resume Examples & Samples

  • Case Reviews to include case preparation for Physician Peer Review Committee meetings
  • Creation of meeting agendas, minutes, compiling packets, facilitating meetings, and reviewing cases with the Physicians
  • Ensuring that strategies and follow-up actions items are communicated to the Providers in a timely manner
  • Conducting various audits to ensure both documentation standards and standards of care are being met
  • Performing facility site audits for new Physician offices
  • Working on various Quality initiatives and partnering with Medical office staff and physicians on implementation
  • Current and unrestricted RN or LVN license in California
  • Proficiency in Microsoft Office: Outlook, Word, Excel & PowerPoint
  • Previous Utilization Management or Quality Improvement experience
  • Inpatient Nursing experience: Acute Care, Medical / Surgical, etc
  • Managed Care work experience
8

Clinical Quality RN Resume Examples & Samples

  • Interface/Liaison with State, Federal and other regulatory bodies
  • Solve problems with facilities, providers, members
  • Assist with resolution of issues
  • Develop policies, procedures and work flows
  • Work within a team
  • Occasional 2nd shift work, rotating on-call weekend work and rotating holidays
  • Daily schedule flexibility is needed and is required based on daily work.*
  • Undergraduate degree or equivalent experience
  • Current/unrestricted RN licensure in the State of Ohio
  • 2+ years of Clinical Experience
  • 1+ years of Care/Case Management experience with High Risk Populations
  • 1+ years of Home and Community Based Waiver Services experience
  • Proficient in Microsoft Office (Word, Excel, Access, PowerPoint, Outlook)
  • Incident reporting
9

Clinical Quality Rn-hedis Resume Examples & Samples

  • 1 years of HEDIS/Stars experience
  • 50 to 75 percent travel
  • Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
  • Good business acumen, especially as it relates to Medicare
10

Senior Clinical Quality RN Resume Examples & Samples

  • Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and indentifying opportunities for quality improvement,
  • Serves as subject matter expert (SME) for assigned HEDIS / State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates
  • Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy
  • Current unrestricted RN licensure required in state of MA or Foreign Medical School Graduate
  • Travel locally up to 75% to physician offices
  • Managed Care experience
  • Experience working in Medicaid and/or Medicare
11

Senior Clinical Quality Rn-cpc Resume Examples & Samples

  • Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS / State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
  • Based on medical record audit findings, provides follow-up education, practitioner intervention, and measurement as needed to drive quality improvement
  • Documents and refers providers’ non-clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer
  • Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications
  • Bachelor’s degree in Science or equivalent work experience
  • Highly preferred health care and insurance industry experience, including regulatory and compliance
12

Clinical Quality RN Resume Examples & Samples

  • Works with an interdisciplinary team to document and report quality measures to meet state regulatory requirements specific to the dual eligible Special Needs Population (SNP)
  • Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care for the dual eligible SNP population
  • Tracks and reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
  • Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
  • Supports Quality Improvement Projects (QIP) by identifying and collecting relevant data, monitors progress and analyzes outcomes. Updates QIP documentation regularly
  • Educates providers and office staff on proper clinical documentation, state-mandated quality metrics specifications, provider profiles and medical record review criteria, to drive quality improvement
  • Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation consistent with state specific measures and technical specifications
  • Develop and implement improvement projects and using data to develop intervention strategies to improve outcomes
  • Current, unrestricted RN license in the state of NJ
  • 2+ years of experience in quality improvement, this includes developing and implementing performance improvement projects
  • 2+ years of project management experience
  • Proficient in Microsoft Excel required; Access preferred
  • Managed Medicaid and/or Medicare experience
  • STARS experience
13

VP Clinical Quality, RN Hedis / Stars Resume Examples & Samples

  • Provides leadership and support in establishing and directing the Quality Program for WellMed
  • Collaborates with physicians to execute the implementation of the clinical quality data initiatives as defined by enterprise and/ Optum LCDO
  • Provides expertise to the training department on HEDIS / STAR measures and tools that support collection of and communication about HEDIS / STAR to the enterprise
  • Develops HEDIS / STAR member and provider engagement strategies
  • Collaborates with WellMed executive team to execute HEDIS / STAR strategies
  • Works with Optum LCDO Quality leadership team to provide HEDIS / STAR reporting and to develop strategic direction
  • Facilitates, integrates, and/or coordinates the implementation and evaluation of identified quality improvement / HEDIS / STAR activities as requested by UHG / UHC or related companies
  • Promotes understanding, communication and coordination of all quality improvement program components
  • Participates in requested evaluations and audits for UHC and other health plans
  • Assists with the development of the QM and UM Work Plan, Evaluation and the monitoring of Work Plan activities as they relate to clinical Performance Improvement
  • Participates in various teams, committees and meetings at any level required to maintain business necessity
  • Maintains current knowledge of regulatory requirements associated with the QI program
  • Leads the coordination and completion of projects with cross-functional teams and senior leaders across medical/nursing/clinical functional areas to achieve targeted clinical strategic performance goals
  • Oversees medical / nursing / clinical workflow mapping, performance monitoring, and coaching site visits in clinic settings using process improvement methodologies to identify workflow gaps and establish future-state recommendations
  • Directs medical / nursing / clinical best practice identification and standardization adoption in clinical settings with cross-functional teams and senior leaders
  • Directs and promotes clinical support for clinic staff and nursing roles (RN / LVN Health Coach) with subject matter expertise and resources for population management, nurse advocacy and development opportunities, and nurse coaching / feedback programs
  • Active and unrestricted Registered Nurse license in Texas or ability to obtain within 90 days post hire
  • 8+ years of management-level experience in managed care Quality programs required
  • 5+ years of experience at the Director level or above
  • Demonstrate knowledge of the business environment and business requirements (e.g., strategy changes, emerging business needs)
  • Knowledge of NCQA HEDIS requirements and CMS STAR requirements
  • Excellent verbal, written communication, presentation, and facilitation skills
14

Senior Clinical Quality Rn-south Maryland Resume Examples & Samples

  • Position is responsible for analysis and review of quality outcomes at the provider level, provider education on quality programs, monitoring and reporting on key measures to ensure providers meet quality standards and implementation of pay for performance initiatives
  • Position conducts audits which occur in accordance with State, CMS or quality related requirements
  • The following further defines what is considered to be in scope with position
  • Computer savvy with strong computer skills to include Word, Excel, Outlook
  • HEDIS / NCQA experience
  • Medicaid / Medicare experience
15

Clinical Quality Rn-k Sign-on Resume Examples & Samples

  • Follow - up actions items are communicated to the Plan and Providers in a timely manner
  • Working on various Quality initiatives
  • 2+ years of Clinical Nursing experience
  • 1 year of Previous Utilization Management or Quality Improvement experience
16

Senior Clinical Quality Rn-baton Rouge Resume Examples & Samples

  • Visit providers’ offices to educate them on clinical measures
  • Provide providers with list of gaps in member services / screenings
  • Work directly with members to educate them about managing their healthcare
  • Perform chart reviews for HEDIS
  • Assist with performance improvement projects
  • RN in state of Louisiana
  • 3+ years clinical nursing experience, preferably in managed care environment
  • Access to reliable transportation
  • Experience presenting to others
  • Ability to create spreadsheets in Excel
  • Experience working with providers’ offices
  • Comfort with reading reports and analyzing data
17

Senior Clinical Quality Rn-telecommute Resume Examples & Samples

  • Responsible for scheduling, conducting and documenting annual reviews, corrective action plans (CAP) and re-reviews of HMO commercial and Medicare Advantage delegated contracted Medical Groups and IPAs within regulatory driven timeframes. Documentation is reviewed for regulatory compliance with CMS, DMHC (state of CA), DOI and NCQA / URAC
  • Responsible for communicating review results, both verbally and in writing, with senior level management. This includes communication with the Medical Director, UM & QI Department Directors at the provider group and Market Medical Directors and Network Management internally
  • Responsible for educating / training the provider group to influence their behaviors that impact compliance regarding clinical processes, denial letters and all NCQA standards and regulatory requirements (DMHC, CMS, DOI, etc.). Creating correspondence, presentations and talking points intended to document findings of studies and communicate results and suggested improvement plans
  • Responsible for conducting analysis of information, interpreting provider results and providing feedback and making recommendations for improvement by monitoring monthly and quarterly performance of assigned medical groups through reporting including appeals & grievances, UM & QM reports, and other data generated internally and externally for the delegated provider groups
  • Considered a clinical subject matter expert on a variety of topics by the provider group and internal departments. Must have the ability to interpret regulatory guidelines and provide suggestions to the provider group on how to operationalize regulatory requirements and accreditation standards
  • Assist with data collection, organization, analysis and follow-up to support QI programs
  • Appropriate clinical license required; RN
  • Clinical operations experience in a PMG, IPA, Hospital and/or health plan setting
  • 5+ years’ experience in Managed Health Care / Insurance environment
  • Highly effective at analyzing data and identifying and articulating opportunities for improvement and innovation
  • Knowledge of NCQA standards, CMS & DMHC regulations
  • Knowledge of Quality Improvement philosophy and techniques
  • Knowledge of Medicare Local Coverage Determination, National Coverage Determination, and MCG criteria desirable
18

Senior Clinical Quality Rn-maryland Resume Examples & Samples

  • Responsible for the reporting and analysis of provider member care quality compliance
  • Bachelor of Science in Nursing
  • Current, unrestricted RN licensure
19

Senior Clinical Quality Rn-telephonic Resume Examples & Samples

  • Responsible for strategically developing clinically oriented provider and community based relationships in order to increase quality scores based on state specific quality measures
  • Responsible for collaborating with provider practices and the community to provide education on state specific quality measures
  • Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives
  • Conducts chart audits which occur in accordance with State, CMS or other requirements as applicable
  • Responsible for direction and guidance on provider-focused clinical quality improvement and management programs
  • Assists contracted providers with analyzing member care, trending quality compliance at the provider level and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS, NCQA and other tools
  • Reports to the Quality Leadership of the Health Plan
  • Current, unrestricted RN licensure required in the state of Florida
  • Experience in Project Management
  • 2+ years of quality improvement experience or other quality experience
  • Experience with Word, Excel (Pivot Tables), PowerPoint and Outlook
  • Role requires travel to physician offices locally up to 25% of their time
  • Access to reliable transportation for field visits
20

Senior Clinical Quality Rn-telecommuter Resume Examples & Samples

  • Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria
  • Supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection, or for other focus studies as directed by the Plan Quality Director
  • Current unrestricted RN licensure required in the state of operation
  • 2+ years of quality improvement experience, or other relevant experience
  • Ability to make formal presentations within the context of their role
  • Basic skills in Microsoft Word, Excel, PowerPoint
21

Tricare Clinical Quality RN Resume Examples & Samples

  • Conducts timely reviews of electronic medical records to meet UHC M&V standards
  • Investigations include research, analysis, and preparation of written and verbal case summaries with recommendations for further actions as necessary
  • Ability to organize and maintains current investigation information about cases through documentation in quality of care and quality of service databases
  • Develops peer review cases and other quality improvement activities identified by deviations from accepted standards of care and monitors corrective action plans
  • Collaborates with Medical Directors on complex care identified in PQIs / SREs as needed
  • 3+ years of medical / surgical experience
  • Ability to work in a fast paced dynamic environment
  • Ability to organize quality data in appropriate reporting format
  • Ability to work in a rapidly changing environment being adaptable and flexible
  • BSN Degree
  • Clinical quality management experience
  • Experience with applying quality of care and utilization standards
  • General knowledge of Medicare, TRICARE, or other government health care program
22

Senior Clinical Quality RN Resume Examples & Samples

  • RN license current and unrestricted in state of residence
  • Bachelor of Arts or Sciences in Nursing
  • 5+ years of clinical RN experience
  • Computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software
  • 3+ years of experience as a manager/supervisor
  • Bi-lingual Candidates Desired (English/Spanish)
  • Competencies and Best Practices for High Performers
  • Coaching experience
  • Understanding of principles of change and ability to drive and motivate staff along the continuum of change
  • Able to work under pressure
23

Senior Clinical Quality Rn-telecommuter Resume Examples & Samples

  • Serves as subject matter expert (SME) for assigned HEDIS/State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State Measure rates
  • Documents and refers providers? non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer
  • Unrestricted RN licensed in the state of Wisconsin
  • Bachelor’s degree in Science
  • 2+ years of quality improvement experience
  • Must be able to travel to physician offices locally up to 50% of their time
24

Senior Clinical Quality Rn-west Valley City Resume Examples & Samples

  • Ability to travel via car throughout the 10 counties we serve in northern Utah
  • Positions in this function include RN roles (with current unrestricted licensure in applicable state)
  • Responsible for clinical quality audits and peer reviews
  • Current unrestricted RN license in the state of Utah required
  • Diploma / Associates degree required
  • 1 + year Clinical experience
  • Skilled in use of computers including MS Windows, Excel, Word, and PowerPoint
  • Must complete all pre - employment evaluation tests
  • Role requires travel to physician offices locally up to 75% of the time
  • Medical record audit experience a plus (medical record review and capturing / documenting appropriate clinical information needed to assure compliance)
  • Bachelor degree highly preferred
  • 2+ years Clinical Quality experience (prefer acute care or managed care setting)
  • Previous HEDIS data collection and medical record/chart review experience highly preferred
  • Previous experience educating Physicians, RNs or other clinical and / or non - clinical employees
25

Clinical Quality Rn-phoenix, Arizona Resume Examples & Samples

  • *This is an office position located in Downtown Phoenix at 1 East Washington Street***
  • Perform clinical documentation review of inpatient and outpatient care delivered to adults, children with Medicaid, Medicare health care benefits through United Health Care Community Plans in Arizona for peer review and internal investigations of Quality of Care concerns
  • Applying clinical knowledge and expertise to determine the degree to which an investigated occurrence increased the likelihood of adverse health outcomes, and determine if the actions taken by healthcare providers were consistent with current professional knowledge and guidelines
  • Create professionally written case summaries for Peer Review, and create written letters to regulatory agencies
  • Presenting cases before a provider advisory committee, peer review in conjunction with the reviewing Medical Director
  • Reviewing plans of correction from providers in response to a substantiated QOC or CI occurrence
  • Taking actions to report CI or other applicable occurrences according to State and Federal guidelines and UnitedHealthcare policy and procedure
  • Effectively interface with internal and external customers, facilities and providers to resolve quality of care concerns, obtain medical records and information
  • Conducting delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare. This includes reviewing samples of contractor work against an audit tool or information found in medical charts
  • Performing on-site audits of residential care facilities such as assisted living facilities or practitioner offices
  • Assisting in the development of oversight tools and processes for clinical quality assessment
  • Manage Multiple tasks and projects and changing priorities; prioritize work products effectively
  • Maintain timeliness for deliverable and Regulator requests
  • Must have the ability to work independently, good critical thinking skills, excellent verbal and written communication skills
  • 5 + years experience working as a Registered Nurse
  • 1 year minimum hospital experience
  • Intermediate skills in Microsoft Office, Word, and Excel ability to work with multiple data bases to retrieve and enter information
  • General knowledge of clinical standards of care, professional nursing procedures, and uses and effects of medications
  • Knowledge of Medicare/Medicaid regulations
  • Previous claims review or quality management experience in a healthcare setting
26

Senior Clinical Quality Rn-columbia Resume Examples & Samples

  • Current unrestricted RN licensure required in the state of Tennessee
  • Proficiency in software applications that include, but are not limited to, Microsoft Word
  • Microsoft Excel, Microsoft PowerPoint
27

Senior Clinical Quality Rn-hedis Rn-dade County Resume Examples & Samples

  • Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS/State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
  • Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
  • Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
  • Documents and refers providers' non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
  • Current unrestricted RN licensure required in the state of Florida
  • Knowledge in Pediatric and Adult HEDIS Measures with an emphasis on Pediatrics
  • Proven track record of working with data extraction, data analysis and excel (pivot tables)
  • Intermediate skill level in software applications that include, but are not limited to, Microsoft Word Microsoft Excel, Microsoft PowerPoint
  • Travel to physician offices locally up to 75% of their time
  • Experience working in Medicaid
  • Health care and insurance industry experience, including regulatory and compliance
  • Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry
  • Bilingual (Spanish) candidates
28

Clinical Quality Rn-telecommute Resume Examples & Samples

  • Materials additionally include information from local, state and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
  • Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education and disparity programs as assigned
  • Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care
  • Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
  • Educates providers and office staff on proper clinical documentation, coding, and billing practices, state - mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
  • Documents and refers providers' non - clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
  • Current unrestricted RN licensure required in state of Kansas
  • 3+ years clinical experience as an RN
  • Travel up to 75% of their time in an assigned territory
  • Medicare Experience
  • Coding Experience
  • Multilingual
29

Clinical Quality RN Resume Examples & Samples

  • *There is an opportunity to work-at-home after the initial training. There are no weekends, nights, on - call or holiday work.***
  • Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
  • Needs to works independently and within an integrated team in a highly matrixed environment
  • May do additional duties as assigned
  • 5+ years clinical experience, or other relevant experience
  • Ability to use databases and prepare reports as needed
  • Multilingual candidates
30

Senior Clinical Quality Rn-new Castle County Resume Examples & Samples

  • Deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
  • Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS / STARS for provider and staff education during field visits
  • Current unrestricted RN licensure required in state of Delaware
  • Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel and Microsoft PowerPoint
  • Experience working in Medicaid and / or Medicare
  • Knowledge of STARS and HEDIS measures
31

Clinical Quality RN Auditor Resume Examples & Samples

  • Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow Optum's / Alere Healths policies, State regulations and Accreditation standards
  • 2 or more years of clinical audit experience
  • Bi-lingual Skills
32

Clinical Quality RN Auditor Resume Examples & Samples

  • In Charge of Spanish Audits
  • Ability to remain a neutral party, negotiate and drive to expected result
  • Bilingual Spanish / English
33

Clinical Quality RN Resume Examples & Samples

  • Clinical quality Case Reviews to include case preparation for Physician Peer Review Committee meetings
  • Ensure that clinical grievances, complaints and complex issues are investigated and resolved
  • Engage with physician and physician staff regarding PCP office performance
  • Experience working with the following quality intiatives-P4P, CMS, STARs
34

Tricare Med / Surge Clinical Quality RN Resume Examples & Samples

  • Identifies potential quality issues (PQIs), and serious reportable events (SREs) by applying best practice standards of care and clinical experience
  • Investigations include research, analysis and preparation of written and verbal case summaries with recommendations for further actions as necessary
  • Communicate in writing to health care providers
  • Assists with focused reviews by abstracting medical records for specified criteria
  • Participates on quality committees and presents cases to peer review quality management committee
  • RN with current, active license without restriction in required state(s)
  • Ability to investigate, analyze, synthesize, and formulate conclusions
  • Intermediate computer skills with emphasis on Microsoft Office software (Windows, Word, Excel, and Outlook)
  • Prior quality experience within a managed care company
  • Excellent interpersonal, communication, and writing skills
  • Detail oriented, highly organized, manage time effectively
35

Tricare Med / Surge Clinical Quality RN Resume Examples & Samples

  • Ability to investigate, analyze, synthesize and formulate conclusions
  • Intermediate computer skills with emphasis on Microsoft Office software (Windows, Word, Excel and Outlook)
  • General knowledge of Medicare, TRICARE or other government health care program
  • Excellent interpersonal, communication and writing skills
36

Senior Clinical Quality Rn-philadelphia Resume Examples & Samples

  • Participates, coordinates and / or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
  • Educates providers and office staff on proper clinical documentation, coding and billing practices, state - mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria, to drive quality improvement
  • Works with providers on standards of care, and advises providers on established clinical practice guidelines and appropriate documentation and billing consistent with state specific measures and technical specifications
  • 2+ years of clinical experience
  • 2+ years of quality improvement experience, HEDIS
37

Clinical Quality RN Resume Examples & Samples

  • Lead clinical quality improvement initiative related to respiratory diseases: COPD, Asthma, URI, Pharyngitis, Bronchitis and other projects as assigned
  • Educate primary care practitioners on clinical and preventive health guidelines, primary care operations best practices, documentation standards and coding for outcome reporting
  • Educate hospital ER directors and free standing urgent care center directors on appropriate guidelines and coding
  • Serve as liaison with community health care facilities and the state of Michigan in large performance improvement projects related to respiratory health conditions
  • Collaborate with pharmacists, physicians, nurses and outreach team members to design, implement and measure improvement strategies related to conditions
  • Research current literature for trends and practices related to respiratory conditions, design indicators, design reports; document and report on improvement efforts Monitor and track HEDIS trends
  • A current, unrestricted RN license in the state of Michigan
  • 2+ years experience in quality, disease, utilization or case management
  • MS Office proficiency, Word required, Excel a plus
  • Must be a self-directed individual with excellent writing skills and ability to collaborate with a team
  • Associate’s degree or higher
  • HEDIS exposure
  • Experience with process improvement
  • A clinical background in managed care
  • Experience working with providers