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This position is responsible for improving network provider performance as measured by regulatory agencies overseeing programs including, but not limited to, HEDIS, CAHPS, HOS and plan regulatory quality programs. The position will involve medical record review and audits, Regulatory and Accreditation research, and the ability to analyze data and workflows to develop and implement training plans that will improve the success of the quality programs. This position will provide both in person and digital training to providers and office staff as it pertains to the quality improvement and population health programs. The position will utilize new technology for efficient delivery of services and use the data to make informed decisions to drive performance metrics across all health plan performance initiatives. This position will also provide education to Hometown Health members and assist with the closure of gaps in care.
The position will provide support with managing the development, implementation, compliance and oversight of Hometown Health’s Quality Improvement and Population Health Programs. Components of this position include but are not limited to, Accreditation, Risk Adjustment, Stars, HEDIS, Quality of Care, and Member Satisfaction. This position will perform other duties as requested.
This position is responsible for conducting comprehensive chart reviews and performing in-depth root cause analyses to identify factors contributing to non-compliance. The individual will develop targeted strategies and implement effective interventions to address identified issues, ensuring compliance with regulatory standards and improving overall quality outcomes. Collaboration with cross-functional teams and continuous process improvement efforts will be essential to drive sustainable corrective actions.
The essential functions of the position are:
• Support collection, analysis, and interpretation of data for ongoing quality management activities of the organization and medical staff, as assigned.
• Collect, analyze, and interpret data and information to support decision-making toward performance improvement.
• Use clinical process measures and outcomes data to develop and execute action plans focused on population health and reducing health disparities
• Abstract data from EMRs for purpose of meeting core program requirements for monitoring.
• Produce accurate, complete, and timely data and reports as scheduled or requested
• Function as a primary resource to providers and site leaders regarding clinical initiatives, including quarterly site visits, trainings, and quality performance review.
• Support the providers through analysis and preparation of ongoing performance measures data
• Apply the FOCUS-PDSA model to facilitate process improvement teams designed to improve the quality and safety of care
• Supports members via telephonic outreach following ED and acute care visits
• Support the ongoing development and review of clinical practice guidelines for the plan
• Under their Registered Nursing license, the Quality Improvement Nurse will use their training and acquired expertise to assess, educate, and provide appropriate nursing advice to members in-person and telephonically.
• Collaborate with appropriate departments to document, investigate and resolve formal or informal quality of care complaints in accordance with plan and state policies, procedures, and requirements.
• Develop and manage clinical performance improvement projects as assigned including but not limited to, the initial and periodic documentation requirements, analysis of data, development of the plan of action, and conducting identified interventions.
• Drive performance by engaging directly in the closure of gaps in care as needed including but not limited to, performing point-of-care testing within your licensure, telephonic outreach to members, results delivery, and education, etc.
• Focuses organizational efforts on the improvement of clinical quality performance measures and identifies population-based member barriers to care. Works collaboratively across multiple departments within Renown Health to identify local-level strategies to overcome barriers and close clinical gaps in care.
• Is actively engaged and collaborative initiatives that support improved member experience. Is actively engaged and collaborative initiatives that support improved member experience.
• Participates in and represents plan at community, collaborative, and other organizational meetings focusing on quality improvement, member education, and disparity programs.
• Excellent skills analyzing reports, documents, and creating spreadsheets & dashboards.
• Ability to review, analyze, and interpret regulatory requirements in a clear and concise manner.
• Ability to work independently with minimal supervision.
This position requires strong collaboration with departmental leadership at both Hometown Health and Renown Health as well as our network of providers.
This position shall participate all in quality improvement and change management procedures and processes.
This position provides limited point of care testing, patient education, and triage, and will include follow up to patients with results of care.
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