Hybrid Position – Must be able to commute to San Mateo County Provider Offices
Only open to candidates residing in California
Opportunity to make a difference in your community
Position not eligible for sponsorship
This position is the lead of designated Quality Programs which include, Potential Quality Issue (PQI) process, Health Effectiveness Data Information Set (HEDIS), Facility Site Review (FSR) and Physical Accessibility Review (PAR). This position actively participates in the development and measurement of quality improvement programs and processes to determine if programs have a reasonable clinical basis and provides input from clinical and regulatory experience. The Quality Improvement Nurse Lead monitors member health outcomes through internal and external data collection to determine effectiveness in maintaining safe care environments that meet regulatory requirements and to ensure members are receiving care that meets evidence-based standards.
· Lead designated activities of HEDIS medical record review, FSR/PAR program, and PQI program, resources and processes to achieve program improvement.,
· Serve as plan’s Facility Site Review Master Trainer:
o Train, evaluate and certify QI RNs to conduct FSRs and PARs and perform periodic inter-rater reliability (IRR) of certified site reviews as required
o Perform FSRs, MRRs, and PARs, monitoring and closing identified corrective action plans, documenting, reporting and communicating findings and results as required
o Conduct pre-contractual reviews with potential contracted providers.
o Develop and implement a site review plan to meet the needs of the department
o Lead the development, validation, and submission of required reports to DHCS for FSR activities, scores, etc.
o Maintain thorough knowledge of the DHCS site review requirements and processes
· Lead annual HEDIS medical record review activities, including oversight and training HEDIS medical record review staff. Project Lead for HPSM with outside vendor(s) for chart review activities.
· Facilitate annual NCQA HEDIS ROADMAP and specified HEDIS audit processes for HPSM. Assist HEDIS Auditors in obtaining supportive documentation for audit.
· Participate in HEDIS conference calls/training including attendance at the annual NCQA HEDIS Update conference and attend the Onsite HPSM Audit prior to the beginning of HEDIS.
· Acts in a lead capacity assist with providing clinical guidance and support to staff regarding various aspects of quality improvement including: development, implementation, measurement, and evaluation activities.
· Performs research and development, coordination, monitoring of various activities and project management duties related to Quality Initiatives.
· Provide comprehensive analysis of measures, barriers, and opportunities, and present results of improvement efforts and ongoing performance measures to management.
· Evaluate current processes for the specific program and perform routine opportunity assessments to determine the effectiveness of interventions/incentives and offer replacements as necessary.
· Implement performance improvement programs as assigned and evaluate, recommend, deploy appropriate tools/technology or internal reporting processes to report on periodic progress for success outcomes and compliance to regulatory requirements as designated.
· Ensure compliance for quality audits and maintains data and process controls.
· Actively support and participate in audits, conference calls and meetings, training, program oversight activities, conferences and other related activities specific to program needs.
· Serve as a knowledge expert for designated Quality programs and act as the conduit for information for the QI Department and the nursing team to and from DHCS, the provider community, etc.
These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply.
Education and experience:
· Bachelor’s degree in health care field.
· Equivalent to at least three (3) three years of work in a health care or managed care environment with responsibility for researching, analyzing, planning, evaluating, or coordinating projects.
Licenses and Certification:
· Active California Registered Nurse (RN) License without restriction.
· Certification as a state FSR Master Trainer.
· Must have own vehicle and valid driver’s license with proof of insurance and conformity with state law minimums and be willing to travel (primarily) in San Mateo County.
· Advanced working knowledge of HEDIS specifications.
· Principles, practices and trends of project management and business administration.
· Medicare and Medi-Cal and regulatory programs.
· Quality tools and data: experience with training and facilitation.
· Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint.
· Ability to use initiative and work independently; organize workload/projects and handle multiple projects simultaneously.
· Demonstrated ability to function effectively as team player and across organizations.
Salary and benefits
The starting salary range depends on the candidate’s work experience.
Excellent benefits package includes:
· HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
· Fully paid life, AD&D and LTD insurance
· Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
· 13 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
· Tuition reimbursement plan
· Employee wellness program
Health Plan of San Mateo (HPSM) is a local County-funded nonprofit manages the health care for over 140,000 low-income people San Mateo County, including all its Medi-Cal eligible residents. HPSM is proud to be an Equal Opportunity Employer and an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.
Job Type: Full-time
Pay: $45.00 – $58.00 per hour
All HPSM employees MUST be residing in and working from the state of California. Employees may come into the office if they wish, or work from home. HPSM will supply work from home equipment.
Ability to commute/relocate:
Work Location: Hybrid remote in South San Francisco, CA 94080
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