Career Center

JOB SUMMARY

Quality Improvement RN implements new and existing healthcare quality improvement initiatives and educational programs as required by Health and Human Services Commission (HHSC), Centers for Medicare and Medicaid Services (CMS), Texas Department of Insurance (TDI), or any other accrediting or regulatory bodies. Ensures maintenance of programs for members in accordance with prescribed quality standards as required by regulators and accrediting organizations. Reviews clinical data for clinical quality complaints; investigate and report on Abuse, Neglect, and Exploitation (ANE); conducts data collection, reporting and monitoring for key performance measurement activities. Provides direction and implementation of NCQA and URAC accreditation surveys and federal/state quality improvements/compliance activities. Contributes to the design of new or to refine existing initiatives to increase Provider/Member/Partners engagement and improve outcomes. Coordinates cross functional efforts internally and externally as needed to support assigned projects. Supports the department with the collection and analysis of related data/information and in the development of strategies/processes to improve performance outcomes.


JOB SPECIFICATIONS AND CORE COMPETENCIES

The Quality Improvement RN contributes to tracking, trending, analyzing, and reporting all data, performance measures, and other required information requested by Health and Human Services Commission (HHSC), Centers for Medicare and Medicaid Services (CMS), Texas Department of Insurance (TDI) or any other accrediting or regulatory bodies. Ensuring all deliverables deadlines are met for the Health and Human Services Commission (HHSC), Texas Department of Insurance (TDI), and any other regulatory bodies. Reviews clinical information and resolves clinical complaints and ANE reports. Monitors and ensures that key quality activities are completed on time and accurately to present results to key departmental management and Quality Improvement Committee.

Implements key quality strategies, which may include initiation and management of provider, member and/or community interventions (e.g., removing barriers to care); preparation for Quality Improvement surveys; and other federal and state required quality activities. Contributes to the design of new or to refine existing initiatives to increase Provider/Member/Partners engagement and improve outcomes.

Creates, manages, and/or compiles the required documentation to maintain critical quality improvement functions. Leads quality improvement activities, meetings, and discussions with and between other departments within the organization. Including HHSC Performance Improvement Programs, HHSC QAPI, CMS QHP Quality Improvement Strategy, URAC Quality Improvement Projects and other studies required by regulators and/or accrediting bodies.

Evaluates project/program activities and results to identify opportunities for improvement and informs management of any gaps in processes that may require remediation supporting the overall QI Program design and Quality Improvement Evaluation as required by regulators and accrediting bodies.

Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans and other duties as assigned.


MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure: Associate degree in nursing and RN License required. License must be active and in good standing.

Bachelor's degree in nursing preferred.

Clinical Quality, Public Health or Healthcare, Certified Professional in Health Quality (CPHQ), Certified HEDIS Compliance Auditor (CHCA) preferred.

Work Experience (Years and Area): 3 years Managed Care experience required; with 1 year of Quality Improvement experience.

Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office (Word, Excel, and Outlook) and Visio