Quality of Care Nurse Specialist

Role Overview

Are you a dedicated Registered Nurse with a passion for quality improvement in Long-Term Services and Supports (LTSS)? Our quality management team is seeking a proactive Quality of Care Nurse Specialist to make a significant impact on members' well-being and drive organizational excellence. In this position, you will be a key player in ensuring high-quality care delivery and regulatory compliance for our LTSS members. You will analyze medical records referred to you by legal, appeals, physicians or the critical incident team to identify quality of care episodes. You will summarize and formally present your findings to the Chief Medical Officer and Market President to determine if a corrective action plan (CAP) should be executed. You will also support the quality improvement department with annual medical record review activities including Healthcare Effectiveness Data and Information Set (HEDIS), National Committee for Quality Assurance (NCQA), and Clinical Practice Guidelines. 

Work Arrangement

• Remote role

• Monday through Friday from 8:00a EST to 5:00p EST

Responsibilities

• Performs clinical Quality of Care (QOC) reviews to include all sentinel events and member concerns. 
• Drive annual medical record review activities, including HEDIS reporting and adherence to Clinical Practice Guidelines.
• Collaborate across departments to support accreditation efforts and implement clinical quality performance improvement initiatives.
• Review and approve the quality management work plan on an annual basis including selection of performance measures, goals, objectives, and thresholds 
• Review and suggest new and/or improved quality management activities using Plan-Do-Study-Act Cycles 
• Assist with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets, schedules, agendas, and the review and approval of minutes.
• Develop and analyze QOC reports for QAPI to identify trends and opportunities for enhancing patient outcomes.

Education and Experience

• Associate’s Degree in Nursing; Bachelor’s Degree preferred
• Minimum of 3 years of clinical experience in critical care required
• Minimum of 3 years in clinical or service quality improvement/ health care delivery or relevant experience required

• Experience managing a complete project lifecycle, from initiation and planning to execution and closing

Licensure

• Active and unencumbered Registered Nurse license

Skills and Abilities

• Knowledge of quality improvement processes and data analysis in managed care
• Expertise in Long-Term Services and Supports (LTSS) program areas
• Competent in Microsoft Office Suite, including document formatting in Word, basic formulas and data entry in Excel, and presentation design in PowerPoint
• Ability to produce error-free documentation and correspondence
• Ability to prioritize effectively and remain productive in a fast-paced environment

• Ability to evaluate complex clinical problems, interpret data from various sources within a record, identify trends or inconsistencies, and draw sound, evidence-based conclusions

Your career starts now. We are looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.