Job Description & How to Apply Below
Remote
Job Summary We are seeking a Quality Management Nurse to support healthcare quality initiatives, including state audits, HEDIS activities, provider quality audits, and quality-related referrals and complaints. The successful candidate will conduct provider office reviews, evaluate medical records and documentation for compliance with quality standards, analyze audit findings, support corrective action plans, and prepare routine quality reports. This role also provides education and training to providers, vendors, and internal staff regarding audit requirements and quality standards.
Key Responsibilities Conduct on-site and virtual provider office reviews to assess the environment, medical record quality, documentation, and compliance with established standards. Review physician medical records and identify documentation deficiencies, quality concerns, and opportunities for improvement. Prepare detailed documentation summarizing audit findings and communicate results with physicians and provider offices. Provide education and guidance to providers regarding documentation requirements, quality standards, and identified improvement opportunities.
Provide data support and analyze quality trends, patterns, and audit results to support quality improvement and health management initiatives. Assist the Quality Management department with special projects, focused clinical studies, and quality improvement initiatives. Support preparation and coordination of state audits and serve as an internal representative/project lead for assigned audit activities. Analyze audit findings and identify recurring deficiencies, trends, and areas requiring corrective action.
Prepare weekly, monthly, quarterly, and year-end reports, as well as other reports requested by management. Coordinate and manage the Corrective Action Plan (CAP) process for assigned audit types. Conduct reaudits/follow-up reviews to verify that previously identified deficiencies have been appropriately addressed. Assist with training internal staff, providers, and vendors on quality programs, audit processes, and applicable standards. Perform other related quality management tasks and special studies as assigned.
Required Qualifications 3–5 years of related professional experience, preferably within healthcare, managed care, health plans, or quality management. Active New Jersey Registered Nurse (RN) license OR valid Licensed Practical Nurse (LPN) license. Valid driver's license and access to a reliable automobile. Knowledge of managed care principles and healthcare quality processes. Knowledge of medical terminology. Strong computer skills and proficiency with standard PC applications.
Excellent verbal and written communication skills. Strong analytical, organizational, and problem-solving abilities. Strong presentation and interpersonal skills. Ability to communicate audit findings professionally and work effectively with providers and internal stakeholders.
Preferred Qualifications
Experience with HEDIS principles and quality measures. Knowledge of URAC accreditation standards.
Experience with health management, patient education, provider education, or quality improvement. Previous experience conducting medical record audits, provider audits, state audits, or quality reviews.
Experience with Corrective Action Plans (CAPs), reaudits, and compliance monitoring. Experience working in a managed care organization, health plan, or healthcare quality department. Key Skills HEDIS, Quality Audits, Medical Record Review, Healthcare Quality, Quality Management, Managed Care, Provider Audits, State Audits, Clinical Documentation, Quality Improvement, Corrective Action Plans, CAP, Compliance, Data Analysis, Trend Analysis, Medical Terminology, Health Management, Patient Education, Provider Education, Reporting, RN, LPN, URAC, Audit Findings, Reaudits, MS Office, Communication, Presentation Skills What We’re Looking For We are looking for a detail-oriented healthcare professional who can independently conduct quality reviews, analyze findings, communicate effectively with providers, and support ongoing quality improvement initiatives.
Candidates should be comfortable balancing clinical knowledge, audit/compliance requirements, data analysis, reporting, and provider education.
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