Clinical Quality Improvement Nurse

Medical Mutual; Cleveland (OH); Hybrid; USD 80,000 - 110,000; Full time

Benefits offered by this job

On-site cafeteria

Gym membership reimbursement

Discounts

Cash rewards

Business casual attire

Job summary

Medical Mutual, based in Ohio, is seeking a Clinical Quality Improvement Nurse for a hybrid-remote position out of the Brooklyn, OH office. The role focuses on applying NCQA and CMS standards, performing chart reviews for HEDIS, and driving quality improvement initiatives across lines of business.

The ideal candidate is a licensed RN in Ohio with 3 years of clinical experience in a health plan, and may hold a BSN or higher. Strong data skills and collaboration with provider groups are essential.

Qualifications

• Graduate of a registered nursing program approved by the Ohio Board of Nursing.
• Bachelor of Science in Nursing preferred; Master’s Degree a plus.
• 3 years clinical RN experience, preferably in a health plan.

Responsibilities

• Collaborates with quality improvement team to support studies, education materials, provider engagement, vendor management and quality initiatives.
• Applies clinical expertise to collect HEDIS/study data through chart review and abstraction.
• Prepares narratives, reports, graphs, and procedures to support quality improvement and accreditation activities.
• Applies process and performance improvement methods to gain insight and measure effectiveness.
• Integrates findings into redesign of processes or clinical practices with cross-functional collaboration.
• Performs other duties as assigned.

Skills

Clinical expertise

Data analysis

Project management

Research & reporting

Quality improvement

Education

RN with Ohio license

BSN preferred

MSN a plus

Tools

PDSA/ DMAIC knowledge

NCQA/HEDIS knowledge

CMS regulations knowledge

Microsoft Office

Job description

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

This is a hybrid-remote role based out of the Brooklyn, OH office, with employees expected to work onsite on designated in-office days each week.

Clinical Quality Improvement Nurse

Job Summary

Applies process improvement methods to daily work to comply with National Committee for Quality Assurance (NCQA), accreditation standards and the Centers for Medicare & Medicaid Services (CMS) regulations for quality. Performs medical record reviews to derive analyses and supporting documentation to enhance NCQA, Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star ratings as well as data analysis to recommend and implement process improvement methods and reporting. Supports and collaborates with provider groups to promote quality and oversight of quality vendors.

Responsibilities

• Collaborates with quality improvement team/management to support the development of studies, education materials, provider engagement, vendor management and quality initiatives that improve the quality of care provided to members across all lines of business.
• Applies clinical expertise to collect HEDIS and/or study data through chart review and abstraction
• Prepares narratives, reports, graphs, charts, flowcharts, and policy and procedures, to support quality improvement and accreditation activities.
• Applies process and performance improvement methods to gain insight and measure effectiveness.
• Integrates output of findings into the redesign of a process or clinical practice. Collaborates cross-functionally to develop and implement project plans.
• Performs other duties as assigned.

Qualifications

Education and Experience:

• Graduate of a registered nursing program approved by the Ohio Board of Nursing.
• Bachelor of Science in Nursing preferred. Master’s Degree a plus.
• 3 years clinical experience as a Registered Nurse preferably in a health plan.

Professional Certification(s)

• Registered Nurse with current State of Ohio unrestricted license
• Certified Professional in Healthcare Quality (CPHQ) or Lean Six Sigma certification preferred.

Technical Skills And Knowledge

• Good project management skills.
• Ability to conduct online research for updates of industry best practices.
• Intermediate Microsoft Office skills – (Word, PowerPoint, and Excel).
• Knowledge of process and performance improvement methods and tools: Plan Do Study Act (PDSA) or Define, Measure, Analyze, Improve and Control (DMAIC).
• Knowledge of NCQA, HEDIS and Medicare Star rating, health plan accreditation standards, and CMS regulations for quality preferred.

A Great Place To Work

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits And Compensation

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment In You

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual

Medical Mutual’s status as a mutual company means we are owned by our policyholders, not stockholders, so we don’t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There’s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We’re not just one of the largest health insurance companies based in Ohio, we’re also the longest running. Founded in 1934, we’re proud of our rich history with the communities where we live and work.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.