Senior RN, Quality
Posted on: October 16, 2020
Full-time Sr. RN Quality, Roma Location Overview of Position:
The Quality Senior RN position is responsible for direction and
guidance on clinical quality improvement and management programs
including accreditation. Conducts clinical quality audits and may
also be responsible for NCQA requirements. Responsible for the
reporting and analysis of member care quality and for the
development of plans and programs to support continuous quality
improvement. Adheres to policies, procedures and regulations to
ensure compliance and patient safety.-- Participation in Compliance
and required training is a condition of employment.Essential
- Review programs, policies and reports to ensure all elements
- Review /interpret / summarize records/data to address quality
of care questions.
- Review records for compliance with regulatory guidelines (e.g.,
NCQA, State, Clinical Practice Guidelines, CMS), verify necessary
documentation is included in records.
- Based on review of clinical data / documentation, identify
potential quality of care issues (e.g., variations from standard
practice potentially resulting in adverse outcomes) and potential
fraud, waste and abuse. Refer issues identified to relevant parties
for further review and actions.
- Load completed information into relevant systems according to
- Report results (e.g., quality improvement initiatives, audits)
to committees, external stakeholders, regulatory agencies, etc. and
respond to questions or solicit feedback and input.
- Anticipates customer needs and proactively develops solutions
to meet them.
- Solves complex problems and develops innovative solutions.
- Reviews work performed by others and provides recommendations
- Develop and discuss with sub-delegates and vendors corrective
- Educate vendors and sub-delegates on criteria and
- Explain/ convey specifications regarding action plans / develop
or update work plans.
- Develop, update, and/or review policies and procedures.
- Review results, conduct analyses (e.g., evaluate against
goals/effectiveness of interventions over time), and prepare
reports on findings.
- Educate, motivate, and/or influence others (e.g., leadership,
other stakeholders), to understand the overall scope, overcome
potential barriers, and engage in and commit to the process.
- Communicate and explain applicable standards and/or technical
specifications and identified gaps and/or changes in applicable
- Work with others to ensure messaging to members and/or
providers is appropriate to the audience, complete/accurate, and
- Train others on relevant policies, rules, or regulations (e.g.,
appropriate release of data, handling protected health
- Serve as a resource providing explanations and expertise.
- Perform other duties as assigned.Education:Required- Associates
Degree in NursingPreferred- Bachelor's degree or higher in
healthcare related fieldExperience:Required - 5 years of clinical
experience+ 1 year of clinical quality experience+ 1 year working
in managed care or in the insurance industryRequired licensure:
Required- Valid NM RN License or valid multi-state compact
licensePreferred- Case Management Certification.Knowledge, Skills,
- Ability to evaluate medical records with attention to detail to
perform quality audits
- Experience with Medicare and/or Medicaid
- Knowledge base of clinical standards of care, preventive health
standards, HEDIS, NCQA, governing and regulatory agency
- Proficiency in software applications that include, but are not
limited to, Microsoft Word, Microsoft Excel, Microsoft
PowerPointAnticipates customer needs and proactively develops
solutions to meet them.Careers with Optum. Here's the idea. We
built an entire organization around one giant objective; make
health care work better for everyone. Optum, part of the
UnitedHealth Group family of businesses, brings together some of
the greatest minds and most advanced ideas on where health care has
to go in order to reach its fullest potential. For you, that means
working on high performance teams against sophisticated challenges
that matter. Here you'll find incredible ideas in one incredible
company and a singular opportunity to do your life's best
work.(SM)Diversity creates a healthier atmosphere: Optum and its
affiliated medical practices are Equal Employment
Opportunity/Affirmative Action employers and all qualified
applicants will receive consideration for employment without regard
to race, color, religion, sex, age, national origin, protected
veteran status, disability status, sexual orientation, gender
identity or expression, marital status, genetic information, or any
other characteristic protected by law. Optum and its affiliated
medical practices is a drug-free workplace. Candidates are required
to pass a drug test before beginning employment.
Keywords: Optum, Albuquerque , Senior RN, Quality, Healthcare , Albuquerque, New Mexico
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