RN Registered Nurse, Quality Compliance & MRR Audit Specialist - Denver Health Medical Plan

We are recruiting for a RN Registered Nurse, Quality Compliance & MRR Audit Specialist - Denver Health Medical Plan to join our team!

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Department

Managed Care Administration

Job Summary

Under limited supervision, the primary responsibility is in planning, implementing, and overseeing Quality Improvement (QI) projects and annual HEDIS medical record reviews, participating in annual Medical Record Review (MRR) training with successful completion of the certification exam, training staff, and conducting inter-rater reliability (IRR) and over-reads of QI staff throughout the medical record review process. Through the medical record review process, identifies clinical issues, abstracts and collects, analyzes clinical data, and prepares reports for various QI initiatives. Uses health informatics in providing solutions, suggests clinical interventions, liaises with other departments, and collaborates with QI team members in the implementation of quality improvement and accreditation initiatives.

Essential Functions :

• Clinical Operations:
  Prepares, plans, and implements for HEDIS medical chart reviews, trains staff, and conducts Inter-Rater Reliability (IRR) and over-reads for the QI department. Identifies issues from medical chart reviews and provides solutions to QI Staff and supports Medical Record Review Audit and Rate Research Review/Validation audits. Supports the development of annual HEDIS medical record review training materials, training QI staff, and conducting inter rater reliability and over-read tasks.
  Documents and communicates clinical issues to QI staff and reviews medical records accurately for specified indicators. Monitors and maintains Quality Improvement initiatives in a timely manner; demonstrates a working knowledge of State and Federal Regulations as well as NCQA standards, while applying them to assigned projects.
  Using sound organizational skills and the ability to prioritize, independently manages work functions related to the position. Conducts Clinical QI studies using HEDISÂ. (65%)
• QI Clinical Studies & Data Analysis:
  Collects, analyzes, and reports, clinical indicators and data from various sources in collaboration with other team members. Reviews reports to analyze information and data needed for specific projects and for statistical validity, accuracy, and trends. Identifies problems with documentation, compliance, and communication and provides appropriate feedback in a timely manner. (20%)
• QI Regulatory Accreditation, Compliance & Clinical Audits:
  Acts as a facilitator for regulatory and other required activities, serves as a clinical educator and resource person working with QI related activities with other departments. Revises QI related policies and procedures and ensures compliance with regulatory requirements as requested, , accreditation, clinical guidelines. Audits and monitors documentation, data, and performance to ensure compliance with quality and safety initiatives and regulatory standards. Participates in regulatory audits. (10%)
• Professional Accountability:
  Develops educational materials and provides education to members and practitioners to help promote quality and safety initiatives and meet regulatory requirements. Attends committee and department meetings and represents the QI Department in other assigned meetings. Responsible for maintaining the confidentiality of all business/ work. Assists in managing the flow of information between internal and external customers. Is a team player and can work independently. Participates in LEAN and performance improvement activities, quality improvement and patient safety activities. (5%)

Education :

• Associate's Degree Nursing Required

Work Experience :

• 4-6 years Compact Licensure of RN with Electronic Medical Record (EMR) documentation experience required and
• 1-3 years Previous experience with medical record review, quality improvement, core/performance measurement, HEDISÂ, CAHPS or CMS Stars Ratings required

Licenses :

• RN-Registered Nurse - DORA - Department of Regulatory Agencies Required

Knowledge, Skills and Abilities :

• Computer proficiency in Microsoft Office and Internet.
• Knowledge of Medicare, Medicaid, NCQA and CMS contracting standards preferred.
• Required skills include collecting and compiling data for QI studies such as medical records, health informatics, decision-making skills regarding appropriateness of care review, assisting with research design planning, analyzing, and generating quality improvement reports.
• Requires the ability to be flexible and handle multiple tasks, simultaneously.
• Requires the ability to communicate in a professional and positive manner and to work independently and consistently meet schedules and deadlines.

Shift

Days (United States of America)

Work Type

Regular

Salary

$71, - $107, / yr

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to , and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF programÂ

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For more about our commitment to diversity visit: