Remote Utilization Review Rn Jobs in Durham, NC (NOW HIRING)

Work Arrangement:

Remote based position with a strong preference for a North Carolina resident. Will support the North Carolina plan. RN required

Responsibilities:

As part of the Quality Management team, the Quality Performance Specialist -Clinical is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing standards of care. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines. The position also supports accreditation and clinical quality performance improvement activities. Strong maternal and / or women's health background strongly preferred.

• Assumes responsibility for performing quality of care reviews to include all sentinel events and member concerns. Coordinates reviews with physician advisors and clinical quality committees as appropriate.
• Assures minimally necessary medical records are collected and organized for clinical review to occur. Summarizes all clinical findings for review by clinical committees as appropriate.
• Assist with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets, schedules, agendas, and the review and approval of minutes.
• Reviews and approves the QM work plan on an annual basis including selection of performance measures, goals, objectives, and thresholds
• Review and suggest new and/or improved QM activities using Plan-Do-Study-Act Cycles
• Develops QOC quarterly trending reports for QAPI for input and direction. Follows up on any recommendations.
• Adheres to QM policies including annual reviews, updates, and approvals.
• Participates and assist in activities and reporting to maintain compliance with state regulations and NCQA standards for quality activities
• Supports the quality improvement department with annual medical record review activities including HEDIS, NCQA and Clinical Practice Guidelines by working collaboratively with the Quality
• Improvement Department. Assistance will be based upon the organizations needs annually but may include participation in the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.
• All other duties as assigned.

Education/Experience:

• Associate's Degree or equivalent work experience, Bachelor's Degree preferred.
• Minimum of 3 years in clinical or service quality improvement/ health care delivery or relevant experience required.
• An unrestricted Clinical license (RN) in the plan's state or any other state he/she works required.
• Prior experience with project facilitation/management preferred.
• Knowledge and understanding of QI functions in an MCO preferred.
• Knowledge of Medicaid and Medicare preferred.
• Proficient with Microsoft Office applications including Word, PowerPoint, Excel required.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.