About the role
Clinical Quality programs are designed to enhance clinical outcomes and concierge-level service to our members, through review of services provided to members from network healthcare providers, facilities and Oscar employees. The Senior Clinical Quality Nurse drives clinical performance through the quality auditing and clinical quality of care review process for the departments they serve. The Clinical Quality Nurse serves as a peer mentor and a consultant, working collaboratively with team members to implement audit programs that reflect departmental goals and measurements, meeting all regulatory and organizational requirements.
You will report into the Nurse Supervisor, UM Clinical Quality.
Work Location
This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; North Carolina; Ohio; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.
Responsibilities
- Perform quality audits on clinical documentation for clinicians from a variety of clinical departments.
- Develop audit surveys and rubrics to ensure the transparency of audit requirements, supporting evidence-based clinical decision making and adherence to department workflows and align with regulatory accreditation requirements.
- Pull clinician and provider cases for auditing purposes, tracking results in department systems and tracking mechanisms.
- Support organizational readiness and preparation for NCQA and other regulatory audits.
- Perform delegate oversight audits, writing audit result summary reports and presenting to stakeholders and delegates. Collaborate with leadership to develop corrective action plans to address identified gaps.
- Provide 1:1 feedback and coaching to front-line staff and leaders regarding departmental workflows and audit requirements and support developing training tools on quality best practices, audit standards and other topics as directed.
- Support developing training tools on quality best practices, audit standards and other topics as directed.
- Collaborate with leadership/stakeholders on audit trends, process changes, training development. Deliver quality-oriented presentations and aggregate quality data to report performance trends to stakeholders.
- Participate in audit calibration sessions with internal staff and stakeholders to ensure audit consistency.
- Participate in the interrater reliability process (IRR) as needed to support consistent clinical decision making across teams.
- Compliance with all applicable laws and regulations.
- Other duties as assigned.
Requirements
- Licensed Registered Nurse with active, unrestricted license in state of residence and willingness to obtain additional licenses as needed for Oscar’s growth (with Oscar’s support)
- 2+ years of experience as a Registered Nurse
- 2+ years experience working in a clinical care setting
- 1+ years of utilization review experience at a managed care plan or provider organization
Bonus points
- Health plan case management experience.
- Experience in healthcare quality assurance, including experience auditing medical records and evaluating clinical information and internal documentation to determine the quality of care and service provided to members.
- Experience in health plan case management.
- Bachelor’s Degree from an accredited university, BSN Preferred.
- A working knowledge of health insurance/benefit concepts - Medicare and Individual Marketplace insurance experience a plus.
- Strong understanding of NCQA accreditation standards for utilization management, case management or population health, HEDIS measures and other regulatory requirements.
- CCM or MCG certification.
- Experience analyzing and interpreting performance and other forms of data.
- Proficiency using Google applications like Sheets, Docs, Slides and Meets.
- Comfortable using Google Meets and other platforms to communicate with internal/external stakeholders.