Clinical Quality Improvement Nurse

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Clinical Quality Improvement Nurse

Job Summary:      

Applies process improvement methods to daily work to comply with National Committee for Quality Assurance (NCQA), accreditation standards and the Centers for Medicare & Medicaid Services (CMS) regulations for quality. Performs medical record reviews to derive analyses and supporting documentation to enhance NCQA, Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star ratings as well as data analysis to recommend and implement process improvement methods and reporting. Supports and collaborates with provider groups to promote quality and oversight of quality vendors. 

Responsibilities:

• Collaborates with quality improvement team/management to support the development of studies, education materials, provider engagement, vendor management and quality initiatives that improve the quality of care provided to members across all lines of business.
• Applies clinical expertise to collect HEDIS and/or study data through chart review and abstraction
• Prepares narratives, reports, graphs, charts, flowcharts, and policy and procedures, to support quality improvement and accreditation activities.
• Applies process and performance improvement methods to gain insight and measure effectiveness.
• Integrates output of findings into the redesign of a process or clinical practice. Collaborates cross-functionally to develop and implement project plans.
• Performs other duties as assigned.

Qualifications:

Education and Experience:

• Graduate of a registered nursing program approved by the Ohio Board of Nursing.
• Bachelor of Science in Nursing preferred. Master’s Degree a plus.
• 3 years clinical experience as a Registered Nurse preferably in a health plan.

Professional Certification(s):

• Registered Nurse with current State of Ohio unrestricted license
• Certified Professional in Healthcare Quality (CPHQ) or Lean Six Sigma certification preferred.

Technical Skills and Knowledge:

• Good project management skills.
• Ability to conduct online research for updates of industry best practices.
• Intermediate Microsoft Office skills – (Word, PowerPoint, and Excel).
• Knowledge of process and performance improvement methods and tools: Plan Do Study Act (PDSA) or Define, Measure, Analyze, Improve and Control (DMAIC).
• Knowledge of NCQA, HEDIS and Medicare Star rating, health plan accreditation standards, and CMS regulations for quality preferred.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes profession