Company Background Healthmap Solutions is the future of specialty health management that focuses on progressive diseases, with a particular expertise in kidney health populations. Healthmap Solutions uses clinical big data resources and high-powered analytics to power complex specialty health management programs. Healthmap Solutions is a diverse, growing company committed to our clients and our employees. We are champions for better health, for those who need us most.Position Summary The Registered Nurse, Quality Assurance Reviewer will work in conjunction with the Quality Manager and will be responsible for completing quality reviews for the Clinical Services and Provider Relations teams and reporting results. The role supports Quality Improvement Programs related to delegation, accreditation, and regulatory standards. The role will collaborate with Clinical Services, Provider Relations, and Clinical Training teams to improve the quality of the Kidney Health Management program and other clinical programs.ResponsibilitiesAudit clinical documentation and audit calls to provide feedback ensuring that delegation requirements related to NCQA, URAC, and client are metEnsure files comply with federal, state, local CMS accreditation standardsSupport clinical operations in pre-delegation, delegation, and accreditation reviewsProvide support to clinical operations in auditing clinical documentation and member facing calls as part of clinical excellence review initiativesMaintain all required quality, organization, and project documentationPrepare and audit files based on regulatory, accreditation, and client requirements in a timely manner to provide key stakeholders an opportunity to correct deficiencies before external auditsPrepare and deliver weekly reporting statistics of audit activities and outcomesAssist with health plan interface and participate in prep for external audits of clinical programBe a subject matter expert who is able to provide innovative solutions to problems and assist quality improvement initiativesNavigate technical applications – Excel, Outlook, PowerPoint, and WordParticipate in the quality testing of platform and products enhancements of our electronic medical records systemOther duties as assignedRequirementsMust be bilingual English/SpanishRN or LPN licensure and a Bachelor’s degree required (8+ years of clinical quality improvement experience will be considered in lieu of degree and/or RN/LPN licensure)Three (3) years of healthcare experience in a care management or quality management setting requiredExperience working in electronic medical records, generating reports and analyzing data requiredKnowledge of regulatory, CMS and accreditation agencies (NCQA and/or URAC) strongly preferredKnowledge of Care Management and Managed Care setting strongly preferredExperience monitoring calls of a clinical staff preferredSkillsEffective verbal and written communicationAdvocate and energize a culture of collaboration, positivity, and motivationPerformance metrics drivenAbility to manage multiple concurrent deadlinesStrong organizational skills and attention to detailMust be proficient in Microsoft Office: Outlook, Word, Excel, PowerPointTravelNo TravelAmericans with Disability SpecificationsThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. As an Equal Opportunity Employer, we will not discriminate against any job candidate or employee due to age, race, religion, ethnicity, national origin, gender, gender identity/expression, sexual orientation, disability, familial status, veteran status, marital status, parental status, or pregnancy. In our innovative and inclusive workplace, we prohibit discrimination and harassment of any kind.
