Clinical Quality RN Resume Samples

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Q Effertz

Queenie

Effertz

83361 Tobin Plain

Chicago

+1 (555) 479 5226

83361 Tobin Plain

Chicago

Phone

p +1 (555) 479 5226

Experience Experience

Houston, TX

Clinical Quality RN

Houston, TX

Greenholt-Upton

Houston, TX

Clinical Quality RN

Serves as subject matter expert (SME) for assigned HEDIS / State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS / State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates
Serve as liaison with community health care facilities and the state of Michigan in large performance improvement projects related to respiratory health conditions
Develop policies, procedures and work flows
Project leader for Network Management and working with Physician Offices
There is an opportunity to work-at-home after the initial training. There are no weekends, nights, on - call or holiday work.
Educate primary care practitioners on clinical and preventive health guidelines, primary care operations best practices, documentation standards and coding for outcome reporting
Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation

New York, NY

Senior Clinical Quality Rn-telecommuter

New York, NY

Lesch LLC

New York, NY

Senior Clinical Quality Rn-telecommuter

This is a telecommuter, work from home position; Candidate should live Trumbull or Ashtabula or surround Country including Lake Geauga, Portage, Mahoning
Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases, and researching to identify members' encounter history
Participates, coordinates, and / or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care
Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Manager and Quality Director
Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned

present

Philadelphia, PA

VP Clinical Quality, RN Hedis / Stars

Philadelphia, PA

Kilback and Sons

present

Philadelphia, PA

VP Clinical Quality, RN Hedis / Stars

present

Plans, organizes, directs the administration of all WellMed Quality Programs
Leads projects with cross-functional teams and senior leaders across medical, nursing, clinical functional areas to achieve targeted clinical strategic performance goals
Provides long-term planning and oversight to ensure quality improvement is integrated into strategic direction and operations as well as the mission and values of the company
Collaborates with physicians to execute the implementation of the clinical quality data initiatives
Provides expertise to the training department on HEDIS and STAR measures and tools that support collection of and communication about HEDIS and STAR to the enterprise
Develops HEDIS, STAR member and provider engagement strategies
Collaborates with WellMed and Optum executive teams to execute HEDIS and STAR strategies

Education Education

Bachelor’s Degree in Healthcare

Tulane University

Bachelor’s Degree in Healthcare

Skills Skills

This is an office position located in Downtown Phoenix at 1 East Washington Street
Perform clinical documentation review of inpatient and outpatient care delivered to adults, children with Medicaid, Medicare health care benefits through United Health Care Community Plans in Arizona for peer review and internal investigations of Quality of Care concerns
Create professionally written case summaries for Peer Review, and create written letters to regulatory agencies
Presenting cases before a provider advisory committee, peer review in conjunction with the reviewing Medical Director
Reviewing plans of correction from providers in response to a substantiated QOC or CI occurrence
Taking actions to report CI or other applicable occurrences according to State and Federal guidelines and UnitedHealthcare policy and procedure
Effectively interface with internal and external customers, facilities and providers to resolve quality of care concerns, obtain medical records and information
Conducting delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare. This includes reviewing samples of contractor work against an audit tool or information found in medical charts
Performing on-site audits of residential care facilities such as assisted living facilities or practitioner offices
Assisting in the development of oversight tools and processes for clinical quality assessment

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Senior Clinical Quality Rn-telecommuter Resume Examples & Samples

*This is a telecommuter, work from home position; Candidate should live Trumbull or Ashtabula or surround Country including Lake Geauga, Portage, Mahoning***
Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Manager and Quality Director
Current unrestricted RN license in the state of Ohio
1 year of Medicare experience
2 year of Medicaid experience
Knowledge & demonstrated experience with continuous Quality Improvement concepts and tools i.e. audits, chart review, knowledge of current CPT and ICD10 coding
Demonstrated presentation and communications skills with clinicians and organizational leaders
Ability to work with and relate to staff and demonstrate active listening skills
Display professionalism and respect cultural differences
Intermediate computer literate and have MS Word, Excel, Outlook, and Internet demonstrated skills
Ability to foster teamwork with all levels of management and staff within highly matrix organization
2 years of HEDIS
Knowledge of CMS guideline

Clinical Quality RN Auditor Resume Examples & Samples

Independently use discretion and judgment to evaluate objective and subjective clinical documentation of member records and engagements to assess performance of nursing skill and the skills of other allied health professionals, based on Business Unit expectations for performance
Consults with Medical Directors to calibrate on subjective assessments to ensure consistency of feedback related to complex, high risk cases
Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow Optum's/Alere Healths policies, State regulations and Accreditation standards
Generate reports /findings of reviews for the Clinical Management Teams: in a clear, concise manner that is understandable and actionable
Provide consultation with Clinical Management leaders as requested to support staff coaching and development efforts
Assist the Clinical Management team, as needed, to determine areas that require immediate remediation and assist Optum’s employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and consumer engagement
Identifies tracks and records best practices, sharing the specifics with team leadership
Participate in training and performance improvement related projects to support staff development as well as assist with the training of new Call Quality employees
The Clinical Quality RN will highlight key findings for implementation of performance improvement plans when necessary
Work with colleagues across business units to ensure that process and procedural changes are reflected in staff member’s documentation such as job aids and policies
Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings
Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings
Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served
Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner
Ability to work and interact with professionals as part of an interdisciplinary team
Able to work independently; self-motivated with good organizational skills
Quickly learn and adapt to new technology
RN required in the state that you reside (must be active and unrestricted)
NICU or Maternal Case Management
Capable to apply and conduct a logical approach to audits to arrive at fact-based recommendations based on source of truth documentation
Ability to remain a neutral party, negotiate, and drive to expected result
Has a passion for quality and performance improvement
Specialty license and experience preferred in Case Management
2 or more years of clinical audit experience preferred
Bi-lingual Skills Desired

VP Clinical Quality, RN Hedis / Stars Resume Examples & Samples

Plans, organizes, directs the administration of all WellMed Quality Programs
Collaborates with leaders to meet operational program needs, ensures compliance with state/federal health plan requirements, Medicare guidelines, NCQA and health plan requirements
Leads projects with cross-functional teams and senior leaders across medical, nursing, clinical functional areas to achieve targeted clinical strategic performance goals
Provides long-term planning and oversight to ensure quality improvement is integrated into strategic direction and operations as well as the mission and values of the company
Develops and maintains policies and procedures that support the corporate initiatives that meet State, Federal legal requirements and standards
Collaborates with physicians to execute the implementation of the clinical quality data initiatives
Provides expertise to the training department on HEDIS and STAR measures and tools that support collection of and communication about HEDIS and STAR to the enterprise
Develops HEDIS, STAR member and provider engagement strategies
Collaborates with WellMed and Optum executive teams to execute HEDIS and STAR strategies
Facilitates, integrates, and/or coordinates the implementation and evaluation of identified quality improvement, HEDIS and STAR activities as requested
Participates in requested evaluations and audits for health plans
Coordinates reporting on quality initiatives to all appropriate committees
Maintains QI program documents, reports, and committee minutes and follows all internal privacy and confidentiality policies and procedures
Oversees HEDIS data submission process to all contracted health plans
Leads accreditation efforts as defined by enterprise
Oversees medical/nursing/clinical workflow mapping, performance monitoring, and coaching site visits in clinic settings using process improvement methodologies to identify workflow
Gaps and establish future-state recommendations
Directs and promotes clinical support for clinic staff and nursing roles (RN or LVN Health Coach) with subject matter expertise and resources for population management, nurse advocacy and development opportunities, and nurse coaching/feedback programs
· ·
Master’s degree in Healthcare or Business Administration required (8 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a Master’s degree)
Active and unrestricted Registered Nurse license in the US with the ability to obtain a Texas license within 12 months of starting employment
Fifteen or more years of management-level experience in managed care, medical management programs required, including five or more years of experience at the Director level or above Knowledge of the business environment and business requirements (e.g., strategy changes, emerging business needs)
HEDIS/STARS expertise
Excellent verbal, written communication, presentation, and facilitation skills Knowledge of fiscal management and human resource management techniques
Ability and willingness to travel both locally and non-locally as determined by business need

Senior Clinical Quality Rn-hedis Resume Examples & Samples

Perform HEDIS medical record review in physician offices throughout the state of Nevada
Complete inter-rater reliability testing and required computer training successfully in order to complete this data collection
Conduct additional QI audits through medical record review
Help with credentialing activities for organizations and facilities such as hospitals and skilled nursing facilities
Educates Physicians, RNs and other clinical employees in the off season
2+ years Clinical Quality experience
Previous experience educating Physicians, RNs or other clinical and/or non-clinical employees
Must be self-motivated and able to learn new computer software quickly
Must be comfortable and proficient in being trained on a data collection software that allows the person to collect and record medical record information accurately on a timely basis
Ability to demonstrate knowledge and to apply to job functions, those state and federal laws and regulations applicable to the operation unit
Previous HEDIS data collection and medical record / chart review experience highly
Medical Record Audit Experience a Plus (medical record review and capturing/documenting appropriate clinical information needed to assure compliance)
2+ years Clinical Quality experience in acute care or managed care setting

Clinical Quality RN Resume Examples & Samples

Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation
Conducts clinical quality audits (CMS Regulations, State Regulations, File and Chart reviews, etc.) and may also be responsible for NCQA, URAC and Joint Commission audit requirements
Responsible for the reporting and analysis of member care quality and for the development of plans and programs to support continuous quality improvement using Microsoft Office Suite or Access
Analyzes and investigates
Responsible for Policy and Procedure Quality and Review
Training on and presenting new processes
Attend, participate and present at Committees as required
Project leader for Network Management and working with Physician Offices
Experience with Medicare/Medicaid, ACO, Stars and HEDIS
Ability to Multitask
RN license in AZ
3 years of experience in a clinical setting
3 years of QA experience
MS Office advanced proficiency is a must
Ability to travel to providers in Maricopa County and trips outside of Maricopa County as required - 20% to conduct audits and review charts, etc
Strong background in Quality Improvement / Management
Certifications in Quality Improvement / Management (Greenbelt, Lean, etc
CTQ
Clinical Database

Senior Clinical Quality RN Resume Examples & Samples

Current unrestricted RN licensure in New Mexico
1+ yrs of experience of Medicare/Medicaid regulations
2+ yrs of clinical experience as an RN
1+ yrs analytical and problem solving skills while managing multiple tasks simultaneously
Proficient in Microsoft Office, Word, and Excel
Knowledge of CMS Hospital Acquired Conditions and Never Events
The applicant should possess a high attention to detail, exceptional documentation abilities, and organizational skills
Proven ability to meet critical deadlines consistently, while completing tasks accurately

Clinical Quality RN Resume Examples & Samples

Case Reviews to include case preparation for Physician Peer Review Committee meetings
Creation of meeting agendas, minutes, compiling packets, facilitating meetings, and reviewing cases with the Physicians
Ensuring that strategies and follow-up actions items are communicated to the Providers in a timely manner
Conducting various audits to ensure both documentation standards and standards of care are being met
Performing facility site audits for new Physician offices
Working on various Quality initiatives and partnering with Medical office staff and physicians on implementation
Current and unrestricted RN or LVN license in California
Proficiency in Microsoft Office: Outlook, Word, Excel & PowerPoint
Previous Utilization Management or Quality Improvement experience
Inpatient Nursing experience: Acute Care, Medical / Surgical, etc
Managed Care work experience

Clinical Quality RN Resume Examples & Samples

Interface/Liaison with State, Federal and other regulatory bodies
Solve problems with facilities, providers, members
Assist with resolution of issues
Develop policies, procedures and work flows
Work within a team
Occasional 2nd shift work, rotating on-call weekend work and rotating holidays
Daily schedule flexibility is needed and is required based on daily work.*
Undergraduate degree or equivalent experience
Current/unrestricted RN licensure in the State of Ohio
2+ years of Clinical Experience
1+ years of Care/Case Management experience with High Risk Populations
1+ years of Home and Community Based Waiver Services experience
Proficient in Microsoft Office (Word, Excel, Access, PowerPoint, Outlook)
Incident reporting

Clinical Quality Rn-hedis Resume Examples & Samples

1 years of HEDIS/Stars experience
50 to 75 percent travel
Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
Good business acumen, especially as it relates to Medicare

Senior Clinical Quality RN Resume Examples & Samples

Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and indentifying opportunities for quality improvement,
Serves as subject matter expert (SME) for assigned HEDIS / State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates
Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy
Current unrestricted RN licensure required in state of MA or Foreign Medical School Graduate
Travel locally up to 75% to physician offices
Managed Care experience
Experience working in Medicaid and/or Medicare

Senior Clinical Quality Rn-cpc Resume Examples & Samples

Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS / State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
Based on medical record audit findings, provides follow-up education, practitioner intervention, and measurement as needed to drive quality improvement
Documents and refers providers’ non-clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer
Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications
Bachelor’s degree in Science or equivalent work experience
Highly preferred health care and insurance industry experience, including regulatory and compliance

Clinical Quality RN Resume Examples & Samples

Works with an interdisciplinary team to document and report quality measures to meet state regulatory requirements specific to the dual eligible Special Needs Population (SNP)
Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care for the dual eligible SNP population
Tracks and reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
Supports Quality Improvement Projects (QIP) by identifying and collecting relevant data, monitors progress and analyzes outcomes. Updates QIP documentation regularly
Educates providers and office staff on proper clinical documentation, state-mandated quality metrics specifications, provider profiles and medical record review criteria, to drive quality improvement
Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation consistent with state specific measures and technical specifications
Develop and implement improvement projects and using data to develop intervention strategies to improve outcomes
Current, unrestricted RN license in the state of NJ
2+ years of experience in quality improvement, this includes developing and implementing performance improvement projects
2+ years of project management experience
Proficient in Microsoft Excel required; Access preferred
Managed Medicaid and/or Medicare experience
STARS experience

VP Clinical Quality, RN Hedis / Stars Resume Examples & Samples

Provides leadership and support in establishing and directing the Quality Program for WellMed
Collaborates with physicians to execute the implementation of the clinical quality data initiatives as defined by enterprise and/ Optum LCDO
Provides expertise to the training department on HEDIS / STAR measures and tools that support collection of and communication about HEDIS / STAR to the enterprise
Develops HEDIS / STAR member and provider engagement strategies
Collaborates with WellMed executive team to execute HEDIS / STAR strategies
Works with Optum LCDO Quality leadership team to provide HEDIS / STAR reporting and to develop strategic direction
Facilitates, integrates, and/or coordinates the implementation and evaluation of identified quality improvement / HEDIS / STAR activities as requested by UHG / UHC or related companies
Promotes understanding, communication and coordination of all quality improvement program components
Participates in requested evaluations and audits for UHC and other health plans
Assists with the development of the QM and UM Work Plan, Evaluation and the monitoring of Work Plan activities as they relate to clinical Performance Improvement
Participates in various teams, committees and meetings at any level required to maintain business necessity
Maintains current knowledge of regulatory requirements associated with the QI program
Leads the coordination and completion of projects with cross-functional teams and senior leaders across medical/nursing/clinical functional areas to achieve targeted clinical strategic performance goals
Oversees medical / nursing / clinical workflow mapping, performance monitoring, and coaching site visits in clinic settings using process improvement methodologies to identify workflow gaps and establish future-state recommendations
Directs medical / nursing / clinical best practice identification and standardization adoption in clinical settings with cross-functional teams and senior leaders
Directs and promotes clinical support for clinic staff and nursing roles (RN / LVN Health Coach) with subject matter expertise and resources for population management, nurse advocacy and development opportunities, and nurse coaching / feedback programs
Active and unrestricted Registered Nurse license in Texas or ability to obtain within 90 days post hire
8+ years of management-level experience in managed care Quality programs required
5+ years of experience at the Director level or above
Demonstrate knowledge of the business environment and business requirements (e.g., strategy changes, emerging business needs)
Knowledge of NCQA HEDIS requirements and CMS STAR requirements
Excellent verbal, written communication, presentation, and facilitation skills

Senior Clinical Quality Rn-south Maryland Resume Examples & Samples

Position is responsible for analysis and review of quality outcomes at the provider level, provider education on quality programs, monitoring and reporting on key measures to ensure providers meet quality standards and implementation of pay for performance initiatives
Position conducts audits which occur in accordance with State, CMS or quality related requirements
The following further defines what is considered to be in scope with position
Computer savvy with strong computer skills to include Word, Excel, Outlook
HEDIS / NCQA experience
Medicaid / Medicare experience

Clinical Quality Rn-k Sign-on Resume Examples & Samples

Follow - up actions items are communicated to the Plan and Providers in a timely manner
Working on various Quality initiatives
2+ years of Clinical Nursing experience
1 year of Previous Utilization Management or Quality Improvement experience

Senior Clinical Quality Rn-baton Rouge Resume Examples & Samples

Visit providers’ offices to educate them on clinical measures
Provide providers with list of gaps in member services / screenings
Work directly with members to educate them about managing their healthcare
Perform chart reviews for HEDIS
Assist with performance improvement projects
RN in state of Louisiana
3+ years clinical nursing experience, preferably in managed care environment
Access to reliable transportation
Experience presenting to others
Ability to create spreadsheets in Excel
Experience working with providers’ offices
Comfort with reading reports and analyzing data

Senior Clinical Quality Rn-telecommute Resume Examples & Samples

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. Documentation is reviewed for regulatory compliance with CMS, DMHC (state of CA), DOI and NCQA / URAC
Responsible for communicating review results, both verbally and in writing, with senior level management. This includes communication with the Medical Director, UM & QI Department Directors at the provider group and Market Medical Directors and Network Management internally
Responsible for educating / training the provider group to influence their behaviors that impact compliance regarding clinical processes, denial letters and all NCQA standards and regulatory requirements (DMHC, CMS, DOI, etc.). Creating correspondence, presentations and talking points intended to document findings of studies and communicate results and suggested improvement plans
Responsible for conducting analysis of information, interpreting provider results and providing feedback and making recommendations for improvement by monitoring monthly and quarterly performance of assigned medical groups through reporting including appeals & grievances, UM & QM reports, and other data generated internally and externally for the delegated provider groups
Considered a clinical subject matter expert on a variety of topics by the provider group and internal departments. Must have the ability to interpret regulatory guidelines and provide suggestions to the provider group on how to operationalize regulatory requirements and accreditation standards
Assist with data collection, organization, analysis and follow-up to support QI programs
Appropriate clinical license required; RN
Clinical operations experience in a PMG, IPA, Hospital and/or health plan setting
5+ years’ experience in Managed Health Care / Insurance environment
Highly effective at analyzing data and identifying and articulating opportunities for improvement and innovation
Knowledge of NCQA standards, CMS & DMHC regulations
Knowledge of Quality Improvement philosophy and techniques
Knowledge of Medicare Local Coverage Determination, National Coverage Determination, and MCG criteria desirable

Senior Clinical Quality Rn-maryland Resume Examples & Samples

Responsible for the reporting and analysis of provider member care quality compliance
Bachelor of Science in Nursing
Current, unrestricted RN licensure

Senior Clinical Quality Rn-telephonic Resume Examples & Samples

Responsible for strategically developing clinically oriented provider and community based relationships in order to increase quality scores based on state specific quality measures
Responsible for collaborating with provider practices and the community to provide education on state specific quality measures
Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives
Conducts chart audits which occur in accordance with State, CMS or other requirements as applicable
Responsible for direction and guidance on provider-focused clinical quality improvement and management programs
Assists contracted providers with analyzing member care, trending quality compliance at the provider level and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS, NCQA and other tools
Reports to the Quality Leadership of the Health Plan
Current, unrestricted RN licensure required in the state of Florida
Experience in Project Management
2+ years of quality improvement experience or other quality experience
Experience with Word, Excel (Pivot Tables), PowerPoint and Outlook
Role requires travel to physician offices locally up to 25% of their time
Access to reliable transportation for field visits

Senior Clinical Quality Rn-telecommuter Resume Examples & Samples

Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria
Supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection, or for other focus studies as directed by the Plan Quality Director
Current unrestricted RN licensure required in the state of operation
2+ years of quality improvement experience, or other relevant experience
Ability to make formal presentations within the context of their role
Basic skills in Microsoft Word, Excel, PowerPoint

Tricare Clinical Quality RN Resume Examples & Samples

Conducts timely reviews of electronic medical records to meet UHC M&V standards
Investigations include research, analysis, and preparation of written and verbal case summaries with recommendations for further actions as necessary
Ability to organize and maintains current investigation information about cases through documentation in quality of care and quality of service databases
Develops peer review cases and other quality improvement activities identified by deviations from accepted standards of care and monitors corrective action plans
Collaborates with Medical Directors on complex care identified in PQIs / SREs as needed
3+ years of medical / surgical experience
Ability to work in a fast paced dynamic environment
Ability to organize quality data in appropriate reporting format
Ability to work in a rapidly changing environment being adaptable and flexible
BSN Degree
Clinical quality management experience
Experience with applying quality of care and utilization standards
General knowledge of Medicare, TRICARE, or other government health care program

Senior Clinical Quality RN Resume Examples & Samples

RN license current and unrestricted in state of residence
Bachelor of Arts or Sciences in Nursing
5+ years of clinical RN experience
Computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software
3+ years of experience as a manager/supervisor
Bi-lingual Candidates Desired (English/Spanish)
Competencies and Best Practices for High Performers
Coaching experience
Understanding of principles of change and ability to drive and motivate staff along the continuum of change
Able to work under pressure

Senior Clinical Quality Rn-telecommuter Resume Examples & Samples

Serves as subject matter expert (SME) for assigned HEDIS/State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State Measure rates
Documents and refers providers? non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer
Unrestricted RN licensed in the state of Wisconsin
Bachelor’s degree in Science
2+ years of quality improvement experience
Must be able to travel to physician offices locally up to 50% of their time

Senior Clinical Quality Rn-west Valley City Resume Examples & Samples

Ability to travel via car throughout the 10 counties we serve in northern Utah
Positions in this function include RN roles (with current unrestricted licensure in applicable state)
Responsible for clinical quality audits and peer reviews
Current unrestricted RN license in the state of Utah required
Diploma / Associates degree required
1 + year Clinical experience
Skilled in use of computers including MS Windows, Excel, Word, and PowerPoint
Must complete all pre - employment evaluation tests
Role requires travel to physician offices locally up to 75% of the time
Medical record audit experience a plus (medical record review and capturing / documenting appropriate clinical information needed to assure compliance)
Bachelor degree highly preferred
2+ years Clinical Quality experience (prefer acute care or managed care setting)
Previous HEDIS data collection and medical record/chart review experience highly preferred
Previous experience educating Physicians, RNs or other clinical and / or non - clinical employees

Clinical Quality Rn-phoenix, Arizona Resume Examples & Samples

*This is an office position located in Downtown Phoenix at 1 East Washington Street***
Perform clinical documentation review of inpatient and outpatient care delivered to adults, children with Medicaid, Medicare health care benefits through United Health Care Community Plans in Arizona for peer review and internal investigations of Quality of Care concerns
Applying clinical knowledge and expertise to determine the degree to which an investigated occurrence increased the likelihood of adverse health outcomes, and determine if the actions taken by healthcare providers were consistent with current professional knowledge and guidelines
Create professionally written case summaries for Peer Review, and create written letters to regulatory agencies
Presenting cases before a provider advisory committee, peer review in conjunction with the reviewing Medical Director
Reviewing plans of correction from providers in response to a substantiated QOC or CI occurrence
Taking actions to report CI or other applicable occurrences according to State and Federal guidelines and UnitedHealthcare policy and procedure
Effectively interface with internal and external customers, facilities and providers to resolve quality of care concerns, obtain medical records and information
Conducting delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare. This includes reviewing samples of contractor work against an audit tool or information found in medical charts
Performing on-site audits of residential care facilities such as assisted living facilities or practitioner offices
Assisting in the development of oversight tools and processes for clinical quality assessment
Manage Multiple tasks and projects and changing priorities; prioritize work products effectively
Maintain timeliness for deliverable and Regulator requests
Must have the ability to work independently, good critical thinking skills, excellent verbal and written communication skills
5 + years experience working as a Registered Nurse
1 year minimum hospital experience
Intermediate skills in Microsoft Office, Word, and Excel ability to work with multiple data bases to retrieve and enter information
General knowledge of clinical standards of care, professional nursing procedures, and uses and effects of medications
Knowledge of Medicare/Medicaid regulations
Previous claims review or quality management experience in a healthcare setting

Senior Clinical Quality Rn-columbia Resume Examples & Samples

Current unrestricted RN licensure required in the state of Tennessee
Proficiency in software applications that include, but are not limited to, Microsoft Word
Microsoft Excel, Microsoft PowerPoint

Senior Clinical Quality Rn-hedis Rn-dade County Resume Examples & Samples

Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS/State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
Documents and refers providers' non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
Current unrestricted RN licensure required in the state of Florida
Knowledge in Pediatric and Adult HEDIS Measures with an emphasis on Pediatrics
Proven track record of working with data extraction, data analysis and excel (pivot tables)
Intermediate skill level in software applications that include, but are not limited to, Microsoft Word Microsoft Excel, Microsoft PowerPoint
Travel to physician offices locally up to 75% of their time
Experience working in Medicaid
Health care and insurance industry experience, including regulatory and compliance
Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry
Bilingual (Spanish) candidates

Clinical Quality Rn-telecommute Resume Examples & Samples

Materials additionally include information from local, state and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education and disparity programs as assigned
Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care
Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
Educates providers and office staff on proper clinical documentation, coding, and billing practices, state - mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
Documents and refers providers' non - clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
Current unrestricted RN licensure required in state of Kansas
3+ years clinical experience as an RN
Travel up to 75% of their time in an assigned territory
Medicare Experience
Coding Experience
Multilingual

Clinical Quality RN Resume Examples & Samples

*There is an opportunity to work-at-home after the initial training. There are no weekends, nights, on - call or holiday work.***
Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
Needs to works independently and within an integrated team in a highly matrixed environment
May do additional duties as assigned
5+ years clinical experience, or other relevant experience
Ability to use databases and prepare reports as needed
Multilingual candidates

Senior Clinical Quality Rn-new Castle County Resume Examples & Samples

Deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS / STARS for provider and staff education during field visits
Current unrestricted RN licensure required in state of Delaware
Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel and Microsoft PowerPoint
Experience working in Medicaid and / or Medicare
Knowledge of STARS and HEDIS measures

Clinical Quality RN Auditor Resume Examples & Samples

Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow Optum's / Alere Healths policies, State regulations and Accreditation standards
2 or more years of clinical audit experience
Bi-lingual Skills

Clinical Quality RN Auditor Resume Examples & Samples

In Charge of Spanish Audits
Ability to remain a neutral party, negotiate and drive to expected result
Bilingual Spanish / English

Clinical Quality RN Resume Examples & Samples

Clinical quality Case Reviews to include case preparation for Physician Peer Review Committee meetings
Ensure that clinical grievances, complaints and complex issues are investigated and resolved
Engage with physician and physician staff regarding PCP office performance
Experience working with the following quality intiatives-P4P, CMS, STARs

Tricare Med / Surge Clinical Quality RN Resume Examples & Samples

Identifies potential quality issues (PQIs), and serious reportable events (SREs) by applying best practice standards of care and clinical experience
Investigations include research, analysis and preparation of written and verbal case summaries with recommendations for further actions as necessary
Communicate in writing to health care providers
Assists with focused reviews by abstracting medical records for specified criteria
Participates on quality committees and presents cases to peer review quality management committee
RN with current, active license without restriction in required state(s)
Ability to investigate, analyze, synthesize, and formulate conclusions
Intermediate computer skills with emphasis on Microsoft Office software (Windows, Word, Excel, and Outlook)
Prior quality experience within a managed care company
Excellent interpersonal, communication, and writing skills
Detail oriented, highly organized, manage time effectively

Tricare Med / Surge Clinical Quality RN Resume Examples & Samples

Ability to investigate, analyze, synthesize and formulate conclusions
Intermediate computer skills with emphasis on Microsoft Office software (Windows, Word, Excel and Outlook)
General knowledge of Medicare, TRICARE or other government health care program
Excellent interpersonal, communication and writing skills

Senior Clinical Quality Rn-philadelphia Resume Examples & Samples

Participates, coordinates and / or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
Educates providers and office staff on proper clinical documentation, coding and billing practices, state - mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria, to drive quality improvement
Works with providers on standards of care, and advises providers on established clinical practice guidelines and appropriate documentation and billing consistent with state specific measures and technical specifications
2+ years of clinical experience
2+ years of quality improvement experience, HEDIS

Clinical Quality RN Resume Examples & Samples

Lead clinical quality improvement initiative related to respiratory diseases: COPD, Asthma, URI, Pharyngitis, Bronchitis and other projects as assigned
Educate primary care practitioners on clinical and preventive health guidelines, primary care operations best practices, documentation standards and coding for outcome reporting
Educate hospital ER directors and free standing urgent care center directors on appropriate guidelines and coding
Serve as liaison with community health care facilities and the state of Michigan in large performance improvement projects related to respiratory health conditions
Collaborate with pharmacists, physicians, nurses and outreach team members to design, implement and measure improvement strategies related to conditions
Research current literature for trends and practices related to respiratory conditions, design indicators, design reports; document and report on improvement efforts Monitor and track HEDIS trends
A current, unrestricted RN license in the state of Michigan
2+ years experience in quality, disease, utilization or case management
MS Office proficiency, Word required, Excel a plus
Must be a self-directed individual with excellent writing skills and ability to collaborate with a team
Associate’s degree or higher
HEDIS exposure
Experience with process improvement
A clinical background in managed care
Experience working with providers