Senior RN, Quality

Company: Optum
Location: Albuquerque
Posted on: October 16, 2020

Job Description:

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 Functions:

• Review programs, policies and reports to ensure all elements are met.
• 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 specifications.
• 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 for improvement.
• Develop and discuss with sub-delegates and vendors corrective action plans
• Educate vendors and sub-delegates on criteria and expectations
• 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 standards
• Work with others to ensure messaging to members and/or providers is appropriate to the audience, complete/accurate, and compliant.
• Train others on relevant policies, rules, or regulations (e.g., appropriate release of data, handling protected health information)
• 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, Abilities:
  • 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 requirements
  • 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