Quality Improvement Nurse Reviewer

Years of experience

3 years

Employment Type


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Required Degree

Bachelor’s Degrees


445 Grant Avenue, San Francisco, CA 94108

Bay Area San Francisco
Required general skills

RN License

Application Email
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Brief job information:

This position is responsible for project management of quality initiatives to improve performance across all lines of business and reports into the QI Director. The scope of quality includes NCQA and URAC, CAHPS, HEDIS reporting, STAR ratings, HOS reporting, Pay for Performance, clinical gaps, adherence to QI standards and all respective interventions. Shares responsibilities with Director of Clinical Services and credentialing staff for on-site visits to physician offices and audits activities and responsibilities related to QI as well as other clinical quality initiatives. Ensures CCHP maintains performance standards that are in compliance with state, federal and other regulatory bodies by developing, implementing, and effectively managing and evaluating departmental personnel, work processes, performance standards and quality improvement initiatives.

Job description:

Facilitate execution of a comprehensive QI program for Healthcare Effectiveness and Data Information Set (HEDIS®) Measures that delivers actionable information to QI team, CCHP departments, and provider network. Develop expertise in knowledge of HEDIS and STAR quality metrics with ability to serve as reference for internal and external stakeholders. Assist with HEDIS submission including but not limited to planning, preparation, data collection, clinical analysis, and care improvement initiatives.  Develop expertise in use of internal tools and databases to execute Hybrid Medical Record Review. QA and identify data integrity issues and report to QI Director. Assist in year-round HEDIS abstraction process and comprehensive preparation for the annual HEDIS submission cycle including training per-diem and/or contract staff. Facilitate survey distribution to collect and report measures of consumer satisfaction and health outcomes perceptions aligned with Medicare Health Outcomes Survey (HOS); Medicare Consumer Assessment of Health Plans Study (CAHPS). Identification and assessment of significant systemic problems through internal surveillance, complaints, or other mechanisms as it relates to HEDIS, STAR and accreditation. Identifies barriers to achievement of highest quality goals, develops strategic solutions to close gaps and oversees the long-range program to improve outcomes. Monitor, execute, and report on Medicare member incentive program that aligns with STAR measure completion, including member and provider communications and incentive fulfillment. Participate in state and federal audits as they relate to quality improvement under guidance from QI Director. Work cross-functionally with Clinical Care Services, Network Management, Risk adjustment team, Member Services, Finance, Government Programs and other leadership to meet and exceed quality and cost targets. In conjunction with QI Director: Facilitate in URAC/NCQA accreditation process. o Participate in internal, Covered CA, and CMS annual Quality Improvement Projects. In collaboration with Director of Clinical Services and credentialing staff: On-site review of physician office and medical records at various sites prior to credentialing and re-credentialing. On-site review of organizational, provider, or vendor sites prior to contracting and re-credentialing, including facilities, SNFs, and LTCF as needed. Educates provider sites on Best Practices and provides guidance on specific findings and areas of concern, reviews Corrective Action Plans and conducts on-site re-inspections as required Assess communication between behavioral health providers and primary care physicians. Performs other duties and special projects as assigned by QI Director.