Quality of Care RN- Interventions

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Quality of-Care RN - Interventions contributes to quality improvement functions and is an active contributor to the Plans implementation/enhancement of new and existing healthcare quality improvement initiatives and education programs. The Quality-of-Care RN-Interventions ensures maintenance of programs for members in accordance with prescribed quality standards; conducts member outreach activities, provides necessary education and guidance to close identified gaps in care, and maintains and ensures necessary reporting and monitoring for key intervention activities. The Quality-of-Care Interventions RN is a key part of the Quality Team working to improve HEDIS and Stars scores while improving the overall health of our members by providing education on clinically recommended preventative care, as well as coordination and support to assist the member in obtaining needed services.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

• Place outreach calls to members identified as having gap(s) in preventative care
• Educate the member on importance of preventative care and screening
• Follow up with members requiring support in taking steps to close care gaps
• Evaluate Health Related Social Needs that may impact the member's ability to access needed services
• Evaluate for ongoing care management needs and make referrals as indicated
• Participate in Quality Workgroups focused on HEDIS, Stars, and other quality measures
• Record member interactions in the clinical documentation system
• Write narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions.
• Meet quality and timeliness standards to achieve individual and departmental performance goals as defined within the department guidelines
• Explain programs and results of programs, and document findings and limitations of department interventions.
• Demonstrate and maintain current working knowledge of the required systems, procedures, forms, and manuals
• Comply with all state and federal regulations for activities performed
• As designated, facilitate quality improvement intervention activities meetings, and discussions with and between other departments within the organization
• Surfaces to Manager and Director any gaps in processes that may require remediation.
• Create and Maintain policies & standard operating procedures of processes to maintain compliance
• Support programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.
• Other duties as assigned

Supervision Exercised:

* None

Supervision Received:

* General direction received weekly from the Senior Manager Delegation and Quality Partnerships

Qualifications:

Education Required:

• Associate's degree general field of study, or post high school nursing diploma

Education Preferred:

* Bachelor's, Master's

Experience Required:

* 2 years of experience as practicing RN in hospital/healthcare setting.

Experience Preferred/Desirable:

* 2+ years of experience in health insurance field

Required Licensure, Certification or Conditions of Employment:

* Successful completion of pre-employment background check

* Active, current, and unrestricted license to practice in the state of Massachusetts as a registration

Competencies, Skills, and Attributes:

Job Skills

Required

* Strong proficiency in use of office equipment including copier, fax machine, scanner, and telephones

* Strong PC proficiency in word processing, spreadsheet, and database software

Preferred

* Advanced PC proficiency

Professional Competencies

Required

• Effective collaborative and proven process improvement skills
• Strong oral and written communication skills; ability to interact within all levels of the organization
• Demonstrated commitment to excellent customer service
• Knowledge and understanding of current trends in healthcare
• Aptitude for aligning process, projects, and people to meet business goals in cross-functional team settings
• Health care payer business knowledge including processes and operational data and functions that support the business
• Maintain confidentiality and privacy
• Capable of investigative and analytical research to make decisions and recommendations based on available information
• Independent and sound judgment with good critical thinking skills
• Knowledge of managed care, utilization management, and quality management
• Establish and maintain working relationships with health care providers, members, and coworkers
• Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards
• Ability to Interpret policies, programs, and guidelines
• Establish and maintain working relationships in a collaborative team environment
• Organizational skills with the ability to prioritize tasks and work with multiple priorities
• Maintains current knowledge of State, Federal and other applicable regulatory/accrediting agency requirements as they apply to department functions

Required Leadership Experience and Competencies

* Ability to use available information to focus project's scope and identify priorities

* Ability to coordinate/lead small projects

* Represent WellSense in the community

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees