Quality Reviewer/Auditor, Registered Nurse

Are you an experienced RN with a strong background in Quality including quality of care reviews, incident investigation, and regulatory compliance? VNS Health Plans is seeking a seasoned clinical professional to play a critical role in reviewing and resolving major incidents and serious adverse events in a hybrid work environment.

In this role, you will lead end-to-end case investigations, ensuring adherence to regulatory requirements while identifying root causes and driving corrective actions. You’ll collaborate across clinical, operational, and compliance teams to not only resolve cases, but also strengthen processes, reduce recurrence, and improve overall quality performance.

This is an opportunity to apply your clinical expertise beyond bedside care, leveraging your knowledge to influence system-wide improvements, enhance compliance, and protect member safety at scale, while benefiting from the flexibility of a hybrid role.

What We Provide

• Referral bonus opportunities    
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays  
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability    
• Employer-matched retirement saving funds  
• Personal and financial wellness programs   
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care    
• Generous tuition reimbursement for qualifying degrees  
• Opportunities for professional growth and career advancement   
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities    

What You Will Do

• Collaborates with clinical management to identify, develop and implement quality improvement standards and criteria that meet program goals. Evaluates effectiveness of standards and recommends changes, as needed.
• Ensures Quality Improvement programs are aligned with CMS Triple Aim framework: improving the patient’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.
• Establishes and communicates protocols and standards of care for a cultural and demographic diverse patient/member population; provides intervention guidelines based on these population health needs.
• Coaches and facilitates performance improvement activities designed to help teams and programs meet and exceed quality scorecard indicators. Instructs management and staff in the meaning and use of data for the purpose of assessing and improving quality.
• Participates in the development of standards and criteria for monitoring compliance with Federal and State regulatory requirements and VNS Health Plans performance standards of care. Develops performance measures and data collection instruments.
• Facilitates quality assurance and utilization review activities with interdisciplinary teams on ways to improve and positively affect the care that is provided to patients/members. Reviews and analyzes changes in the health status and outcomes of patients/members utilizing outcomes data. Consults and collaborates with clinical staff to identify trends and opportunities for improvement in health status and outcomes.
• Collaborates with operations management in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies.
• Conducts audits of patient/member case records. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology.
• Collaborates with operations management to assure compliance with CMS and DOH requirements. Coaches, facilitates and monitors continuous improvement to attain strategic quality objectives and industry benchmarks for patient/member outcomes, satisfaction, cost and regulatory requirements.
• Collaborates with Education department in the development of and implementation of quality related training programs.
• Keeps informed of the latest internal and external issues and trends in utilization and quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies and procedures to address these trends.
• Performs onsite medical record reviews for HEDIS or other related compliance or quality improvement initiatives.
• Participates in the development and implementation of quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, Quality Scorecard, IPRO Projects, and CMS Quality Projects.
• For RN Quality Reviewer only:
• Provides clinical support in the Grievance and Appeals process.
• Follows-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.
• Investigates patient/member related complaints and quality of care (QOC) issues, incidents, and serious adverse reportable events in collaboration with internal staff and providers. Performs utilization and quality assessment review; identifies and analyzes results; prepares investigation summary report; and creates/implements corrective action plan as appropriate. Provides education about identified quality trends, outcomes of reviews and new requirements.
  
  

Licenses and Certifications:

• License and current registration to practice as a registered professional nurse preferably in New York State required 

Education:

• Bachelor's Degree in health care administration, human services or business administration or related discipline or the equivalent work experience in a related professional field required

Work Experience:

• Minimum of four years clinical experience in a health care setting, including at least two years with a focus on quality improvement and measurement or related experience required

• Knowledge of health care delivery systems, patient care, care coordination, and clinical processes required

• Ability to perform statistical/quantitative analysis required

• Excellent oral, written and interpersonal communication skills required

• Knowledge of basic Performance Improvement tools and methodologies preferred