RN Clinical Quality and Oversight Consultant
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Job Description
RN Clinical Quality and Oversight Consultant ensuring compliance with federal and state regulations. Planning and executing quality oversight activities for Capital Blue Cross.
Responsibilities:
- Responsible for planning and executing documentation/case audits (internal and external) for assigned unit
- Responsible for educating staff on findings, and the audit tool to ensure a consistent approach to documentation and case collaboration.
- Monthly, quarterly, annually and upon request, prepares written evaluation of quality and oversight activities for assigned unit(s) to ensure regulatory/accreditation/contract compliance
- Establishes appropriate benchmarks and analyzes reports to determine if utilization and quality performance are appropriate.
- Identify opportunities for improving processes and outcomes.
- Development and monitoring of corrective action plans and follow-up activities.
- Maintains appropriate documentation of records, reports, correspondence, training and additional quality and oversight activities
- Actively engages in Capital’s compliance activities, including that of any delegated UM vendors, if applicable
- Assists in ensuring that letters remain in compliance with accreditation and regulatory standards for Capital and any delegated UM vendors, if applicable for assigned unit.
- If applicable to assigned unit, development and implementation of various quality activities including: IRR question development and assessment for assigned unit staff, including development and education of identified areas of opportunity
- Perform routine mock audits for UM, both CMS and NCQA focused.
- Participates in all regulatory and accreditation reporting activities.
Requirements:
- Minimum of five (5) years recent clinical experience
- Two (2) years of experience in Quality Improvement or experience with similar related activities required
- Must have active current and unrestricted master’s level Behavioral Health clinical license (LMSW, LCSW, LISW, LPC, or comparable) or Registered Nurse licensure.
- Certification in quality improvement preferred.
Benefits:
- Medical, Dental & Vision coverage
- Retirement Plan
- Paid Time Off
- Holidays
- Volunteer time off
- Incentive Plan
- Tuition Reimbursement
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