Provides consultative services and manages quality improvement activities and initiatives for Provider Services. Contributes to the development of whole system measures and annual Enterprise quality strategic plan. Implements, monitors, and evaluates quality improvement strategies based on national benchmark data to achieve top decile performance. Analyzes performance and recommends improvement initiatives and/or corrective actions. Utilizes a quality improvement framework, such as Six Sigma - Define, Measure, Analyze, Improve and Control or Plan, Do, Study, Act, to facilitate rapid cycle improvement strategies. Serves as a consultative resource to quality improvement committees and work groups. Integrates compliance and regulatory requirements into QI processes. Understands and interprets CMS/DOH standards and related policies and procedures. Works under general direction.

$49.55 - $61.96 Hourly

What You Will Do

• Collaborates with clinical management and field clinicians to identify, develop and implement quality improvement standards and criteria that meet program goals. Evaluates effectiveness of standards and recommends changes, as needed.
• Ensures Quality Improvement programs are aligned with State and National Quality Standards to achieve best in class quality outcomes as evidenced by better health for individuals, better health for populations, and lower costs for healthcare.
• Coaches and facilitates performance improvement activities designed to help teams and programs meet and exceed quality scorecard indicators. Instructs management and staff in the meaning and use of data for the purpose of assessing and improving quality.
• Participates in the development of standards and criteria for monitoring compliance with Federal and State regulatory requirements and VNS Health Provider Services performance standards of care. Develops performance measures and data collection instruments.
• Reviews and analyzes changes in the health status and outcomes of patients utilizing outcomes data. Consults and collaborates with clinical staff to identify trends and opportunities for improvement in health status and outcomes.
• Collaborates with operations management in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies.
• Investigates patient related complaints and quality of care (QOC) issues, incidents, and serious adverse reportable events in collaboration with internal staff and providers. Performs focused and comprehensive quality assessment reviews; identifies and analyzes results; prepares investigation summary reports; and creates/implements corrective action plan as appropriate. Analyzes data sets for trends and formulates opportunities for improvement based on those trends. Provides education about identified quality trends, outcomes of reviews and new requirements.
• Follows-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.
• Conducts audits of patient case records. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology.
• Collaborates with operations management to assure compliance with CMS/DOH/COP/CHAP requirements. Coaches, facilitates and monitors continuous improvement to attain strategic quality objectives and industry benchmarks for patient/member outcomes, satisfaction, cost and regulatory requirements.
• Participates in the coordination, review, revision and approval of policies and procedures for Provider Services. Identifies gaps and recommends creation of new policies.
• Drafts and ensures annual review and updates of Home Care policies; project manages the annual review of VNS Health operation policies.
• Participates in the preparation for and assists with site visits of outside surveyors/regulators for the purpose of regulatory compliance and accreditation.
• Collaborates with Education department in the development of and implementation of quality related training programs and/or corrective action training related to identified deficiencies.
• Leads and/or participates on quality improvement committees and projects related to performance improvement, measurement and documentation.
• Keeps informed of the latest internal and external issues and trends in quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies and procedures to address these trends.
• Manages the discharge appeal process, including inbox monitoring, chart reviews, clinician and manager interviews.

VNS Health Plan only:

• Assists with analysis of member satisfaction surveys and audits including but not limited to the CMS Health Outcomes Survey, Consumer Assessment of Health Care Providers and Systems or internal satisfaction surveys. Collaborates with Health plan staff to develop initiatives and action plans to improve member satisfaction.
• Performs onsite medical record reviews for HEDIS or other related compliance or quality improvement initiatives.
• Provides clinical support in the Grievance and Appeals process.
• Participates in the development and implementation of quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, SNP Structure and Process, Quality Scorecard, IPRO Projects, and CMS Quality Projects.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

• Current license and registration to practice as a Registered Professional Nurse. required
• Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs.

Education:

• Bachelor's Degree in Nursing required
• Master's Degree in Nursing preferred

Work Experience:

• Minimum of three years of clinical experience in a health care setting, including at least two years with a focus on quality improvement and measurement required
• Knowledge of health care delivery systems, patient care, care coordination, and clinical processes required
• Ability to perform statistical/quantitative analysis required
• Proficiency in word, excel and PowerPoint required
• Experience in EMR navigation such as EPIC or HCHB required
• Excellent oral, written and interpersonal communication skills required
• Knowledge of basic Performance Improvement tools and methodologies required
• Experience in home care and/or hospice preferred