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Clinical Outcomes and Quality Lead RN

Health & Clinical Services
2650 Total Views

Bring your drive for excellence, team orientation and customer commitment to Independence Blue Cross; help us renew and reimagine our business and shape the future of health care.  Our organization is looking to diversify, grow, innovate and serve, and we are looking for committed, empowered learning-oriented people to join our team.  If this describes you, we want to speak with you.

Clinical Quality RN

The Clinical Quality Lead position will be responsible for ongoing management of the completion of field data collection for HEDIS within their geographical territory. The Clinical Quality Lead will oversee a team of field data collection nurses during HEDIS season, as well as collect and review medical records for Pay for Performance and NCQA accreditation projects. The Clinical Quality RN will focus on tasks that occur in accordance with HEDIS, CMS or other requirements as applicable. Position reports to the Manager of Quality Analytics.

This position requires training in the office for 3 weeks. There is an opportunity to work-at-home after the initial training. This role will cover the entire state of NJ as well as the Philadelphia 5-county region.

Primary Responsibilities:

·       Serves as subject matter expert (SME) for HEDIS/STARs Measures.

·       Serves as liaison with key vendors supporting HEDIS/STARs Measures.

·       Reports individual member quality of care trends of concern to the Manager of Quality Analytics, Quality Director and or Plan Medical Directors.

·       Coordinates and performs onsite clinical evaluations through medical record audits to determine compliance with quality metrics, compliance with service delivery and quality standards.

·       Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion.

·       Educates providers and office staff on proper clinical documentation, state-mandated quality metrics specifications and medical record review criteria, to drive quality improvement.

·       Documents and refers providers' non-clinical/service issues to the appropriate internal parties.

·       Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation consistent with state specific measures and technical specifications.


Required Qualifications:

·       Current unrestricted RN licensure required in state of operation

·       5+ years clinical experience

·       2+ years of quality improvement experience

·       Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint

·       Travel to physician offices locally up to 75% of their time

Preferred Qualifications:

·       Experience working in Medicaid and/or Medicare

·       Health care and insurance industry experience, including regulatory and compliance

·       Knowledge of one or more of the following: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry

·       Strong leadership skills with ability to multi-task and think independently


About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.


At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations.  For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!

Equal Employment Opportunity

Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. 

Agency Disclaimer

All resumes submitted directly to an Independence Blue Cross employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process. 

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