Quality Care Coordinator

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Quality Care Coordinator. This position develops, implements and provides ongoing monitoring of intervention plans and quality gap closure. The overall goal of this role is to reduce medical costs and improve quality ratings. The Quality Care coordinator achieves this goal through member and/or provider engagement, internal quality process improvement work, and coordination of overall clinical intervention strategies. The Quality Care Coordinator conducts HEDIS and year-round medical record reviews and is responsible for ensuring that Network Health meets all OCI, CMS and NCQA quality requirements. This role will have varying areas of focus depending on business need, this coordinator could be the SME for quality, condition management, clinical integration or the clinical support for the appeals and grievance process.

Job Responsibilities:

• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health.
• Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies.
• Provide direct outreach to members and/or providers in order to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars and NCQA.
• Creates written materials for members, physicians, and other customers in formats such as newsletters, brochures, self-care materials, educational handouts, letters and telephone scripts.
• Responsible for development and coordination of member centric programs in alignment with industry and regulatory standards.
• Evaluates utilization patterns, medical records and other metrics to monitor quality and efficiency results.
• Provides clinical support for the appeals and grievance department and quality of care complaint process, preparing cases for medical director review when needed.
• Identifies opportunities for improvement and implements clinical interventions.
• Prepare and/or deliver presentations for Quality Management committee, clinic or provider education, and system-wide committees as needed.
• Coordinates, monitors and documents quality interventions and care management programs with goal of effectiveness that promotes value added care and service.
• Collaborates closely with secondary providers (Breathe at Ease, Home Telemetry, Diabetes programs) to coordinate services for members.
• Functions as a liaison when needed for family, member and provider to communicate any current of potential issues.
• Prepares reports as necessary.
• Develop review and revise department policies and procedures including preventive services requirements.
• Provides recommendations for preventive services medicine and evidence based clinical guidelines, seek approval and monitor for updates or relevant changes as assigned.
• Research, submit and evaluate quality improvement projects regulated by CMS as assigned.
• Implements systems of care that facilitate close monitoring of members to promote early intervention.
• Assist with updating and maintaining Clinical Integration (CI) manual and documentation related to CI including reports.
• Assist with meeting directly with CI providers (frontline staff) to answer questions and come up with action plans related to CI contract, other related Clinical integration meetings that require clinical representative.
• Manage CI provider quality improvement fund including quarterly updates, follow-up, and report out on results
• Assist with CI PCP attribution process and supplemental data including troubleshooting electronic medical record access.
• Assist with CI provider project management.
• Other duties as assigned.

Job Requirements:

• Associate degree in nursing required
• BSN preferred
• 4 years clinical RN experience
• Experience in basic data analysis, quality improvement, or HEDIS medical record review, preventive care, or health plan experience preferred
• WI Registered Nurse (RN) license required

*This position is eligible for working remote. Candidate must live within the state of Wisconsin.

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.