Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
Conducts focused reviews, quality studies, and quality improvement projects according to appropriate contract standards. Investigates medical records retrospectively for potential quality and utilization issues. Ensures compliance with the program requirements for Clinical Quality Management (CQM) for Veterans and/or DoD beneficiaries. Maintains URAC standards in work products.
Education & Experience
- Registered Nurse with current unrestricted license in appropriate state
- 1 year experience in Quality Management
- 1 year experience in data analysis and writing clinical quality studies
- 5 years Medical/Surgical experience
- US citizenship and a favorably adjudicated DOD background investigation if selected to work under TRICARE/DoD Contract
- Bachelor’s degree in Nursing or CPHQ
- Experience with team facilitation and project management
- Experience with Medicare, Veteran’s Administration, TRICARE, or other government health care programs
Key Responsibilities
- Conducts research and writes clinical quality studies to identify, develop and evaluate processes to improve delivery of care to Veterans and/or DoD beneficiaries.
- Acts as facilitator on quality improvement team projects and utilizes appropriate quality improvement methodologies and standardized quality management tools.
- Leads and performs quality management audits.
- Identifies, develops, and monitors focused reviews and other quality studies.
- Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records. This includes researching, investigating, analyzing, and preparing case summaries with recommendations for further review.
- Reviews Potential Quality Issues with Medical Directors when appropriate.
- Prepares peer reviewed cases for quality committees and monitors corrective action plans.
- Uses data management software to identify physician practice patterns, over- and under-utilization of care and services, complication rates, and high-cost outliers.
- Prepares and submits activity and projects reports.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.
Technical Skills: General knowledge of Medicare, Veteran’s Administration, TRICARE, or other government health care programs; knowledge in the application of clinical criteria; proficient with Microsoft Word, Excel, and PowerPoint.
Working Conditions
- Ability to work overtime, if needed
- Onsite: Works within a standard office environment
- Remote: Private and secure work-space and work station with high speed internet is required
- Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone