Clinical Quality RN Job Description
Clinical quality RN
provides care that meets professional standards of practice and meets regulatory requirements.
Clinical Quality RN Duties & Responsibilities
To write an effective clinical quality RN job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical quality RN job description templates that you can modify and use.
Sample responsibilities for this position include:
Collect and review medical record data (HEDIS) to show compliance and improvement compared to peers
Pass HEDIS IRR at 100% after training completed each year
Review and Research HEDIS records with accuracy and timely
Pass HEDIS MRRV with no major issues found
Work flexible hours throughout the HEDIS season as needed
Participates in URAC and NCQA survey prep and onsites
Experience with Medicare/Medicaid, Stars and HEDIS
Implement the Quality Improvement Program to meet all clinical regulatory and accreditation requirements
Review medical records for appropriate and timely health care and service
Analyze clinical data, identify root causes and opportunities for improvement
Clinical Quality RN Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Quality RN
List any licenses or certifications required by the position: CPR, ACLS, BLS, CNL, ART, CPHQ, CPC, RN, BART, AHA
Education for Clinical Quality RN
Typically a job would require a certain level of education.
Employers hiring for the clinical quality RN job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Nursing, Graduate, Education, Healthcare, School of Nursing, Science, Associates, Nursing Program, Health, Health Care
Skills for Clinical Quality RN
Desired skills for clinical quality RN include:
NCQA
HEDIS
Of: clinical standards of care
Preventive health standards
Governing and regulatory agency requirements
Medicare market
Governing and regulatory agency requirements and the managed care industry
Products and competitors
Managed care industry
Medicare and TDI regulatory standards
Desired experience for clinical quality RN includes:
Create documentation and clinical studies to submit to regulatory and accrediting bodies
Participate on teams to develop and implement quality improvement initiatives
Knowledge of and utilizes statistical approaches, measurement techniques, including benchmark and comparative data to develop quality reports
Collects, aggregates, analyzes, summarizes and reports quality data for hospital organizational performance and physician performance data as indicates
Participates in hospital-wide outcomes and quality improvement initiatives/ performance improvement teams
Assists in efforts to improve and streamline the process and workflow of the department
Clinical Quality RN Examples
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Clinical Quality RN Job Description
Job Description Example
Our growing company is hiring for a clinical quality RN. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical quality RN
- Clinical Operations Analysis (monitors and analyzes medical management activities
- Responsible for scheduling, conducting and documenting annual reviews, corrective action plans (CAP) and re-reviews of HMO commercial and Medicare Advantage delegated contracted Medical Groups and IPAs within regulatory driven timeframes
- Responsible for communicating review results, both verbally and in writing, with senior level management
- Considered a clinical subject matter expert on a variety of topics by the provider group and internal departments
- Compliance to state, CMS, and federal regulations
- Conducts audits of UM and/or CM processes and files
- Writes/reviews policies and procedures
- Provides feedback reports to business partners on findings
- Reviews and assesses content of correction action plans
- Develops and implements accreditation review tracking system
Qualifications for clinical quality RN
- Appropriate clinical license required
- Requires a BA/BS in a clinical or health care field
- MS or advanced degree in a health care related field
- Bachelor's Degree in Nursing highly desired
- Maintains accreditation library
- Creates/updates audit tools, guidelines and reports, standardized policies and procedures
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Clinical Quality RN Job Description
Job Description Example
Our innovative and growing company is looking for a clinical quality RN. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical quality RN
- Ensure processes are in place to support compliance with all state and federal laws (HIPAA), regulatory requirements, accrediting agencies (NCQA and URAC) ValueOptions Federal Services inc. ® clinical criteria and policies and procedures
- Conducts on-site audits of prospective and existing physicians and independent practice groups
- Conducts audits of the UAS State assessment tool
- Ensures that both utilization and quality programs meet criteria
- Compiles and maintains statistical data
- Prepares reports for management that define and evaluate problems and propose solutions
- Educates staff and may conduct training meetings based upon audit results
- Supports the efforts of the agency in managing quality of clinical care, utilization, documentation, outcome & process management through education, associate interaction, & electronic review of patient records & reporting systems * Training & development of clinical staff in OASIS, coding & documentation competencies are critical components of this role * Responsible for outcome management through implementation of best clinical practices and working within a team environment
- Identifies key clinical quality and patient safety measures
- Prioritizes and executes performance improvement plans related to clinical performance
Qualifications for clinical quality RN
- Current driver’s license with positive driving record required
- Proven ability to handle multiple tasks simultaneously by working independently, part of a team, in a fast paced environment
- Bachelor’s degree in nursing or other healthcare-related discipline, plus five years of related clinical core measures/quality/performance improvement work experience in a large acute care hospital that demonstrates the attainment of the requisite job knowledge, skills and abilities
- Knowledge of current medical management systems is preferred
- Experience with UM or CM case file auditing is preferred
- Medicaid Experience and reporting and analytics experience
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Clinical Quality RN Job Description
Job Description Example
Our growing company is hiring for a clinical quality RN. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical quality RN
- Coordination of work completed by HEDIS project coordinators
- Performs documentation and process analysis, identifies clinical best practices and works with stakeholders to improve processes
- Assists with the development, piloting, use, and validation of data collection methodologies
- Report audit results and provide recommendations to market leaders and stateside regulatory compliance area
- Assist with evaluating and analyzing ad hoc quality performance data to develop strategies for implementing Performance Improvement initiatives
- Working under the direction of the Director, maneuvers multiple tasks independently with a fast-paced proactive vs
- Identifies existing facility best demonstrated practices
- Develops presentations, work plans, timelines and milestones
- Implements facility level clinical performance improvement projects with hospital executives and facility multidisciplinary teams under the direction of CQI leadership
- Drives improved clinical outcomes through the deployment of standard toolkits, processes and clinical assessments
Qualifications for clinical quality RN
- Current unrestricted license or certification in applicable field preferred
- Works independently with minimal instruction
- Master’s Degree or equivalent experience and education is preferred
- Certified Professional in Health Care Quality (CPHQ), a certificate in Risk Management from the American Hospital Association or an Associate in Risk Management designation from the American Institute of Insurance is desirable
- Experience in Risk Management or Performance Improvement in an acute care hospital setting is required
- Critical to this position is the ability to interpret and implement requirements of regulatory agencies, including Title 22, California Department of Public Health, and the Joint Commission
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Clinical Quality RN Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of clinical quality RN. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for clinical quality RN
- Collaborates with Corporate and Facility leaders on the hand off and completion of all initiatives
- Assist in the development and revision of Fraud & Abuse department policies and procedures
- Conduct provider education, as necessary, regarding audit results
- Design and maintain reports, auditing, tools and related documentation
- Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company polices and procedures
- Maintain or exceed designated quality and production goals
- Participate as needed in special projects and other auditing activities
- Participate in training programs to develop a thorough understanding of the materials presented
- Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services
- Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned
Qualifications for clinical quality RN
- A thorough knowledge of SMC’s medical staff, organizational and administrative structure is required
- Knowledge of adult education principles is required
- This position requires analytic, problem resolution, persuasion and negotiation skills
- This position exhibits self-direction, independent judgement, discretion and ability to work with a team
- Computer skills are also required
- Expressing ideas by means of the spoken word or clear speech is required
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Clinical Quality RN Job Description
Job Description Example
Our growing company is looking for a clinical quality RN. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical quality RN
- Responsible for clinical quality audits (chart review) and peer reviews
- Investigates variances and potential risk issues, performing root-cause analysis where appropriate
- Provides training and education to Practice Administrators and new providers as part of the on-boarding and orientation process
- Serves as Quality liaison for NGPG practices and providers, assisting in the development of performance improvement plans and projects
- Responsible for reviewing medical records, and abstracting clinical data elements for quality measures aligned with ACO contractual criteria
- Use system derived data to identify and intervene prospectively for potential quality gaps, process variation, unwarranted use patterns
- Enters quality measure data into appropriate quality databases and interfaces to facilitate reporting
- Responsible for learning/maintaining current knowledge of ACO quality program requirements
- Participates in ACO performance improvement initiatives as it relates to quality measures
- Utilizes Lean principles of design and integrate these principles into daily work plans to avoid waste, redundancy or unnecessary rework
Qualifications for clinical quality RN
- Hearing and vision corrected within normal reference range
- A thorough knowledge of medical staff, organizational and administrative structure is required
- Bachelor of Science in Nursing and/or has completed applicable
- Active Arizona RN license
- 2 - 4 years or more of previous clinical experience
- Previous Medicare and commercial experience a plus