• Job Description

  Req#: 44652
  Role Overview: The Quality Performance Specialist - Clinical supports the Quality Management (QM) team by leading and coordinating clinical quality reviews of member concerns and medical records, ensuring adherence to established standards of care. This role plays a key part in quality improvement initiatives, accreditation readiness, and annual medical record reviews, including Healthcare Effectiveness Data and Information Set (HEDIS) and Clinical Practice Guidelines.
  
  Work Arrangement:
  
  • Remote - Fully remote position; may be performed from any location within the United States
  • Availability required during Eastern Standard Time (EST) hours
  • Reliable high-speed internet required (minimum 50 Mbps download / 5 Mbps upload)
  • Associates residing in states where reimbursement is required by contract, law, or regulation may submit eligible expenses for reimbursement
  
  Responsibilities:
  
  • Lead quality-of-care (QOC) reviews, including member concerns and sentinel events; collaborate with physician advisors and clinical quality committees
  • Collect, organize, and review medical records; summarize findings for evaluation and decision-making
  • Support accreditation activities and clinical quality performance improvement initiatives
  • Recommend and implement quality improvement initiatives using Plan-Do-Study-Act (PDSA) methodology
  • Produce quarterly QOC trending reports for QAPI committees and track follow-up actions
  • Ensure compliance with QM policies, including annual reviews, updates, and approvals
  • Participate in regulatory and accreditation reporting to maintain compliance with state requirements and National Committee for Quality Assurance (NCQA) standards
  • Partner with the Quality Improvement team on annual medical record review activities, including tool development, training, testing, and audits
  • Perform other duties as assigned
  
  Education & Experience:
  
  • Associate's degree in nursing is required
  • Bachelor's degree in nursing is preferred
  • Active, unrestricted Registered Nurse (RN) license required
  • Minimum 3 years of experience in clinical quality improvement, healthcare delivery, or a related field
  • Experience with project facilitation or project management preferred
  • Experience working in an HEDIS project
  • Knowledge of Quality Improvement (QI) functions within a preferred Managed Care Organization (MCO)
  • Familiarity with Medicaid and Medicare programs preferred
  • Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) required
  
  Licensure:
  
  • Active, unrestricted Registered Nurse (RN) license required
  
  Skills & Abilities
  
  • Strong knowledge of clinical quality standards, regulatory requirements, and accreditation processes (e.g., NCQA)
  • Ability to analyze medical records and identify quality-of-care trends and gaps
  • Effective collaboration skills with clinicians, physician advisors, and cross-functional teams
  • Strong organizational skills with the ability to manage multiple priorities and deadlines
  • Clear and concise written and verbal communication skills, including report development
  • Experience with quality improvement methodologies such as Plan-Do-Study-Act (PDSA)
  • Detail-oriented with the ability to synthesize complex clinical information into actionable insights
  • Proficient in data tracking, reporting, and Microsoft Office tools

• About the company

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