Quality Compliance Nurse

About the position Humana is seeking a Quality Compliance Nurse to support the Wisconsin Medicaid market. This role performs duties to support optimized performance on key quality indicators including, but not limited to, HEDIS, 5 Star, Pay-for-Performance (P4P), satisfaction surveys, Annual Quality Reviews (AQR), and External Quality Reviews (EQR). The Quality Compliance Nurse fosters a culture of quality improvement by designing projects and studies in collaboration with appropriate teams that directly impacts members by ensuring data accuracy in reporting, investigation, auditing, and improvement opportunities. Assist with the overall Quality Assessment Performance Improvement (QAPI) program including compliance with State, Federal, and other managed care regulatory bodies, QAPI mandates, audits, performance improvement projects and reports. Use continuous Quality Improvement process through tracking and trending data including clinical analysis and reporting for quality monitoring and improvement. Ensure data integrity/maintain efficiency of data collection/maintenance systems. Provide clinical direction as needed to staff dedicated to grievance/appeals and credentialing/re-credentialing functions; and as needed to staff dedicated to review, analysis and response to quality concerns, reportable incidents, and statements of deficiency. Assist with and provide clinical direction as needed to design, implement, and analyze mandated quality and performance improvement projects. Assist department director in the development, maintenance, and execution of quality documents including work plan, evaluation, program description, and Model of Care (as appropriate for Medicare). Provide technical and content-specific expertise to other departments relevant to the identification of, tracking and analysis, and remediation of quality concerns. Perform internal audit reviews of system processes to ensure compliance with regulations, policies, procedures. Track, trend, synthesize, develop, and distribute written information and reports for internal and external requirements regarding the following: QAPI program; and QI activities (studies, surveys, audits, peer reviews, etc.) Assist in the development, implementation, analysis, and follow-up for performance improvement, chronic care improvement, and quality improvement programs. Analyze and investigate quality of care concerns, reportable incidents, Statements of Deficiencies (SOD). Coordinate as needed with partners to schedule and re-schedule reviews/audits. Accurately complete provider (acute, primary, long term care, etc.) audits (may include medical record reviews). Assist in development, implementation, and analysis of satisfaction surveys (provider and member). Assist in the preparation of improvement action plans when deficiencies are identified, monitors and assures that re-evaluation activities are completed and recommendations for improvement have been implemented. Represent Humana/iCare on pertinent internal and external committees and appropriate meetings. Provide clinical direction as needed to non-clinical QI personnel. Participate in the preparation of materials for Quality Management & Improvement Committee (QMIC), Long-Term Care Quality Improvement Committee (LTC-QIC), and the Care Management Quality Improvement Committee (CM-QIC). Assist department management in the development and implementation of new programs for improving and sustaining operating effectiveness and efficiencies. Gain subject matter expertise in existing analytical tools, and clinical dashboards while providing feedback and guidance in the selection and development of new tools. Analyze data to produce reports and clinical dashboards used in developing strategies and activities for improvement. Collaborate with Care Management Department in the implementation of performance initiatives to ensure improvement in HEDIS, 5-Star, Pay for Performance initiatives, and any other contract compliance quality performance projects. Collaborate with Network Development Department in the implementation of acute, primary and long-term-care provider monitoring.

Responsibilities

• Support optimized performance on key quality indicators including HEDIS, 5 Star, Pay-for-Performance (P4P), satisfaction surveys, Annual Quality Reviews (AQR), and External Quality Reviews (EQR).
• Foster a culture of quality improvement by designing projects and studies.
• Assist with the overall Quality Assessment Performance Improvement (QAPI) program.
• Use continuous Quality Improvement process through tracking and trending data.
• Ensure data integrity/maintain efficiency of data collection/maintenance systems.
• Provide clinical direction to staff dedicated to grievance/appeals and credentialing/re-credentialing functions.
• Assist in the development, maintenance, and execution of quality documents.
• Perform internal audit reviews of system processes.
• Track, trend, synthesize, develop, and distribute written information and reports.
• Assist in the development, implementation, analysis, and follow-up for performance improvement programs.
• Analyze and investigate quality of care concerns.
• Coordinate with partners to schedule and re-schedule reviews/audits.
• Accurately complete provider audits.
• Assist in development, implementation, and analysis of satisfaction surveys.
• Assist in the preparation of improvement action plans.
• Represent Humana/iCare on pertinent internal and external committees.
• Participate in the preparation of materials for Quality Management & Improvement Committee.
• Assist department management in the development and implementation of new programs.
• Gain subject matter expertise in existing analytical tools.
• Analyze data to produce reports and clinical dashboards.
• Collaborate with Care Management Department in the implementation of performance initiatives.
• Collaborate with Network Development Department in the implementation of provider monitoring.

Requirements

• State of Wisconsin licensed RN or have a compact license.
• 2 years of experience working as an RN.

Nice-to-haves

• Experience with data collection, analysis and reporting.
• Prior work experience with and knowledge of both Medicare and Medicaid.
• 1-3 years managed health quality assurance experience.
• Experience leading quality improvement plan development and implementation.
• Prior work experience and knowledge of Long Term Care.

Benefits

• Medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.

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