Remote Quality Assurance Auditor Nurse (RN), Care Management (Evolent Health)
- Specialty License RN
- State License(s) any
Quality Assurance Clinical Auditor for Care Management (QA)
Evolent Health is seeking a Quality Assurance Clinical Auditor who will be responsible for managing the quality review process for care management programs. This position will be responsible for ensuring that appropriate practices are being utilized and documentation meets established compliance standards consistently to support department and regional care management compliance. Results of case reviews will be reported monthly to the Population Health Operations Managers and Director. The QA Clinical Auditor supports the Operations’ managers with quality improvement in the clinical area. This will include, but is not limited to, researching quality concerns, root cause analysis with recommendations for remediation provided to management and senior leaders. The QA Clinical Auditor will review calls and documentation and provide feedback to individuals and management pertaining to their adherence to quality standards, appointment booking guidelines and other appropriate Standards of Practice, Job Aids. The QA Clinical Auditor will serve as an advisor to management, supervisors, and trainers to identify process, systems and training needs to aid process improvement.
- Responsible and accountable to the Director of Quality and Regulatory Compliance
- Review clinical documentation and if available, staff phone recordings against program descriptions, workflows and internal policies in alignment with evidence based clinical guidelines, NCQA guidelines, CMS guidelines and regulatory guidelines (when applicable).
- Audits Care Management documentation of CM staff’s case interventions, completion of phone calls and actions, interventions applicable to meeting goals of Care Management program
- In collaboration with CM Managers, can provide support with coaching and mentoring the care managers in the use of communicating with care techniques, documentation requirements for Care Management program requirements and NCQA guidelines
- Generate monthly Care Management Quality reports on Staff performance to submit to Clinical Operations Manager. Provide analysis of data to drive scorecards, action plans and continuous improvement of programs, in addition to program delivery and outcomes
- Identify and escalate situations which may pose quality, compliance, and safety risks that may adversely affect business operations
- Responsible for assisting with development and annual review of the Care Management guidelines in partnership with Care Management Operations Managers and Director.
- Responsible for assisting with development, review, revision and maintenance of Care Management quality audit tool guidelines as needed or at least annually.
- Evaluates learning needs of the staff and collaborates with management team to coordinate learning and training opportunities with utilizing the Care Management Training team. Training of staff will be monitored for effectiveness and impact of outcomes from enhanced training
- Provides written feedback to managers and supervisors concerning quality concerns pertaining to individual performance, compliance risks/trends, root cause analysis and any system or process improvements recommended.
- Maintains monthly statistics to track and communicate the number and type of concerns on a monthly basis to the care management team. Clearly and concisely presents findings directly to managers and senior management.
- Identifies system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations.
- Participates in NCQA Committee meetings for Care Management, Care Management Committee monthly meetings and any other meetings assigned.
- Participate in external survey or audits, as needed
- Acts as a liaison with other areas and business units
- Works closely with Director of Quality, Regulatory Accreditation Director and Evolent Health’s Compliance leadership to assist with collaboration on strategic NCQA guidance and CMS guidance based on regulatory releases for Care Management programs
- Participates in development of market/organizational action plans and programs designated to enhance the quality and compliance posture of the organization
- Maintain patient/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPPA) and professionalism to departmental standards, policies and protocols
- Basic Qualifications:
RN degree in Nursing
• Current Registered Nurse license
• Five years of nursing experience
- Knowledge of Care Management processes and regulatory requirements with NCQA
- Demonstrated strong clinical knowledge base, judgment, and experience
- Ability to analyze, integrate, and use quantitative data information in making business decisions and problem solving.
- Excellent attention to detail, organization skills and problem-solving skills.
- Ability to multi-task in a fast paced, team environment and flexible with adapting to change
- Experience working with a virtual team with variable reporting relationships
- Establish and maintain effective working relationships with all levels of employees, other business segments and clients
- Working knowledge of Excel, Power Point and Visio.
- Preferred Qualifications:
Bachelor’s Degree preferred.
• Knowledge of Identifi platform preferred.
• Certified Case Manager and/or National certification in a nursing specialty, administration, education, or other related field.
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