Quality Care Coordinator

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The Quality Care Coordinator develops, implements, and provides ongoing monitoring of intervention plans and quality gap closure. The overall goal of this role is to reduce medical costs and improve quality ratings through member and/or provider engagement, internal quality process improvement, and coordination of clinical intervention strategies. The Coordinator conducts HEDIS and year‑round medical record reviews and ensures compliance with OCI, CMS, and NCQA quality requirements.

Applicants must reside in Wisconsin. This position is eligible for home office (reliable internet required), at our office in Brookfield or Menasha, or a hybrid model.

1.0 FTE, 40 hours per week, 7:30 am – 5:00 pm, Monday through Friday.

• Provide direct outreach to members and/or providers to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars, and NCQA.
• Create written materials for members, physicians, and other customers in formats such as newsletters, brochures, self‑care materials, educational handouts, letters, and telephone scripts.
• Develop and coordinate member‑centric programs in alignment with industry and regulatory standards.
• Evaluate utilization patterns, medical records, and other metrics to monitor quality and efficiency results.
• Provide clinical support for the appeals and grievance department and the quality‑of‑care complaint process, preparing cases for medical director review when needed.
• Identify opportunities for improvement and implement clinical interventions.
• Prepare and deliver presentations for the Quality Management Committee, provider education sessions, and system‑wide committees as needed.
• Coordinate, monitor, and document quality interventions and care‑management programs to promote value‑added care and service.
• Collaborate closely with secondary providers (e.g., Breathe at Ease, Home Telemetry, Diabetes programs) to coordinate services for members.
• Act as a liaison when needed for families, members, and providers to communicate current or potential issues.
• Prepare reports as necessary.
• Develop, review, and revise department policies and procedures, including preventive services requirements.
• Provide recommendations for preventive services medicine and evidence‑based clinical guidelines, seek approval and monitor updates or relevant changes as assigned.
• Research, submit, and evaluate quality improvement projects regulated by CMS as assigned.
• Implement systems of care that facilitate close monitoring of members to promote early intervention.
• Assist with updating and maintaining the Clinical Integration manual and related documentation.
• Meet directly with CI providers (frontline staff) to answer questions and develop action plans related to CI contract and related meetings.
• Manage CI provider quality improvement fund, including quarterly updates, follow‑up, and report‑out on results.
• Assist with CI PCP attribution process and supplemental data, including troubleshooting electronic medical record access.
• Assist with CI provider project management.
• Perform other duties as assigned.

• Bachelor’s degree in a related field required;
  Bachelor’s degree in Nursing preferred.
• Four years of clinical RN experience preferred.
• Experience in basic data analysis, quality improvement, HEDIS medical record review, preventive care, or health‑plan experience preferred.
• Wisconsin Registered Nurse (RN) licensure preferred.

• Seniority level:
  Mid‑Senior level
• Employment type:
  
  Full‑time
• Job function:
  Other
• Industry: Insurance

Network Health is an Equal Opportunity Employer.