Quality Assurance Nurse

2 months ago

Honolulu, Hawaii, United States AlohaCare Full time
Position Overview

Company Overview:

AlohaCare is a community-focused, non-profit health plan dedicated to serving individuals eligible for both Medicaid and Medicare. We strive to deliver comprehensive managed care to our members through strong collaborations with reputable healthcare providers and community health centers. Our mission is to embody the spirit of aloha by advocating for equitable access to quality healthcare for all. We emphasize preventive care and primary health services through our established community health centers, aiming to foster a healthier Hawaii.

Work Environment:

At AlohaCare, our employees are united by a commitment to support Hawaii's underserved populations. This dedication is reflected in our nurturing and positive workplace culture, which promotes a healthy work-life balance, open communication, and a robust benefits package. Our leadership encourages employee engagement through diverse initiatives, recognition programs, and educational opportunities. We prioritize honesty, respect, and trust in our interactions, fostering an environment of two-way communication through regular meetings and events. Our comprehensive benefits include affordable medical, dental, and vision insurance, a PTO program, 401k contributions, referral bonuses, and pre-tax transportation options.

Role Summary:

The Quality Improvement Nurse plays a crucial role in upholding the highest standards in quality improvement initiatives. This position requires collaboration with administrators, healthcare staff, and providers to enhance the quality of care and services delivered to AlohaCare members. The Quality Improvement Nurse operates under the supervision of the Quality Program Manager or other leadership within the Quality Improvement department.

Key Responsibilities:

  • Evaluate data to identify trends, improvement opportunities, and the success of interventions.
  • Formulate and execute strategies aimed at improving member outcomes and overall care quality.
  • Ensure adherence to local, state, and federal regulations, along with accreditation standards.
  • Assist healthcare providers and AlohaCare staff with training and education related to Quality Improvement protocols.
  • Support AlohaCare members in Quality Improvement activities as needed.
  • Facilitate the orientation and training of new Quality Improvement Department personnel in collaboration with leadership.
  • Contribute to Quality Improvement initiatives, including but not limited to:
    • Conducting audits
    • Reviewing medical records
    • Preparing and presenting reports on quality metrics and improvement efforts
    • Developing policies and procedures
    • Participating in committees and workgroups
    • Implementing Clinical Practice Guidelines
    • Engaging in HEDIS and NCQA Accreditation activities
    • Addressing potential Quality of Care issues and Adverse Events
    • Overseeing Performance Improvement Projects
    • Performing other assigned duties
  • Collaborate with interdisciplinary teams to design and implement quality improvement projects.
  • Support quality initiatives across internal departments (e.g., Credentialing, Health Services, Grievance and Appeals, PHM).
  • Maintain confidentiality of AlohaCare's information in compliance with policies and applicable laws.
  • Perform additional job-related tasks as directed by Quality Improvement leadership.

Qualifications:

  • Associate's degree in nursing.
  • At least 2 years of clinical experience.
  • Proven ability to assess, evaluate, and interpret clinical data.
  • Capacity to work independently with minimal supervision.
  • Strong interpersonal skills to collaborate effectively with members, physicians, and healthcare providers.
  • Excellent planning, organizational, analytical, and time management abilities.
  • Clear communication skills, both verbal and written, across departments and with members and providers.
  • Basic computer proficiency, data analysis skills, and familiarity with spreadsheet and database applications.
  • Intermediate skills in Microsoft Office software.
  • Exceptional written and verbal communication capabilities.
  • Strong organizational skills with the ability to manage multiple tasks.
  • Understanding of healthcare regulations and accreditation standards.

Licensure/Certification Requirements:

  • Current and unrestricted Registered Nurse (RN) license in the State of Hawaii.
  • Valid State of Hawaii Driver's License and access to a reliable, insured vehicle.

Preferred Qualifications:

  • Minimum of three years of clinical experience; experience in an acute care setting is advantageous.
  • Familiarity with Quality Improvement/Quality Assurance principles and methodologies, as well as healthcare research methodologies and coding systems (ICD-9, ICD-10, CPT).
  • Prior experience in a managed care environment is preferred.

Equipment Utilized:

  • Computer workstation, printer, copier, fax machine, and telephone.
  • AlohaCare Policy and Procedure Manual.
  • QUEST Policy and Procedure Manual.
  • CMS/Medicare/NCQA Standards.

Mental, Physical, and Environmental Requirements:

  • Frequent travel across all islands in Hawaii, including ground and air travel.

· May require prolonged sitting for up to 4 hours.

· Requires operation of a computer workstation, including keyboard and video display terminal.

· Ability to communicate effectively via telephone and in group settings.

· May involve occasional lifting of up to 20 pounds.

· Requires verbal and written communication in English with members and providers.

· Work may be performed in high-stress environments with multiple deadlines.

· Frequent travel throughout the state of Hawaii is necessary for conducting quality reviews or provider training. Personal transportation is required for off-site travel.

AlohaCare is dedicated to providing equal employment opportunities to all applicants in accordance with applicable laws and regulations. We maintain a policy of non-discrimination and harassment based on various protected characteristics.

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