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The Senior Quality Assurance Clinical Professional may assist with the development of policies, procedures, and methods to ensure operational quality and compliance standards are met. The Senior Quality Assurance, Clinical Professional, supports and implements programs to establish high quality standards in clinical products and services. They will collaborate with the manager and other leaders in training, coaching, and management in areas such as quality improvement and process management. Maintains communications with administration, medical staff and other disciplinary departments regarding quality assurance activities. The Senior Quality Assurance Professional will make decisions on moderately complex to complex issues regarding technical approach for project components. Work assignments are varied and will require interpretation and independent determination of appropriate courses of action.
You will provide support to the Healthcare Quality Reporting and Improvement (HQRI) Provider Support Team (PST) in developing and completing quality assurance check points for all HQRI PST initiatives. This position is accountable for producing a quality assurance framework that aligns with corporate strategies for HQRI and may work in collaboration with other departments.

Position Responsibilities

• Ensures mandatory reporting completed.

• Supports and implements programs to establish high quality standards clinically.

• Collaborates with leaders in training, coaching, and management for quality and process improvement.

• Will assist the compliance audit nurse with complying, conducting, and summarizing audits/reports to include deficiencies and risks for compliance.

• Summarizes issues and analyzes data daily, weekly, monthly, or as needed to assess outcome and operational metrics.

• Support, develop and operationalize methods to drive program and service consistency.

• Proficiency in analyzing, tracking, and interpreting data trends for operational readiness and maintaining state and federal compliance.

• Ensures DMAS Cardinal Care Guidelines, NCQA, CMS, and Humana's Healthy Horizon's Policy and Procedures are followed.

• This is mainly a virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met.

• Ensures timeliness of work and stays in communication with leadership as needed.

• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal to no direction and receives guidance where needed.

• Other duties as assigned per CM or Quality leadership.

Use your skills to make an impact
 

Required Qualifications

• Active Registered Nurse license in the state of Virginia or obtain a multi-state license that participates in the enhanced compact licensure, (eNLC) without disciplinary action

• Minimum three, (3) years clinical experience preferably in an acute, skilled or rehabilitation setting

• Minimum three, (3) years of care management nursing experience

• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment

• Previous experience with Managed Care Organization, with knowledge of Medicaid and Medicare.

• Quality Assurance, compliance and/or auditing experience.

• Ability to work independently under general instructions and with a team.

• Exceptional oral and written communication & interpersonal skills with the ability to build rapport with internal and external customers and stakeholders.

Preferred Qualifications

• Bachelor’s degree in nursing

• Previous DMAS, CMS, HEDIS, and NCQA experience 

• General nursing experience (Med/Surg, ED, ICU preferred)

• Inpatient and outpatient medical record review and auditing experience.

Workstyle:  Remote work at Home

Location: Virginia or reside within 40 miles of one of the following contiguous bordering states - Tennessee, West Virginia, North Carolina, Maryland, or Kentucky

Schedule: Monday - Friday 8:00 AM to 5:00 PM Eastern

Travel: 25% travel within the Commonwealth of Virginia for meetings or compliance assurance audits

Work at Home/Remote Requirements To ensure Hybrid Office/Home assoc