Quality Improvement - Clinical Quality Program RN (STARS) 195-2023

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

CommunityCare HMO Inc. seeks a Registered Nurse to lead Stars Quality initiatives, improving preventive care, closing gaps in care, and boosting Medicare Advantage STARS ratings. You will collaborate with interdisciplinary teams to ensure high-quality, cost-effective care for members.

This role emphasizes population health, care coordination, and navigating social determinants of health to optimize outcomes and member experience within a managed care setting.

Qualifications

• Graduate from nursing program with RN licensure.
• BSN preferred; experience in managed care is a plus.
• Strong clinical judgment and care coordination skills.
• Experience using EHRs and clinical software for documentation.

Responsibilities

• Monitor and close gaps in care for preventive screenings and chronic disease management (HEDIS/STARS).
• Coordinate services across the care continuum and post-discharge follow-ups.
• Engage members via phone or secure messaging to support self-management.
• Document interactions in EHR and participate in quality improvement activities.
• Educate providers and staff on population health initiatives and quality metrics.
• Advocate for patients and address social determinants of health.

Skills

Clinical assessment

Critical thinking

Problem-solving

Communication skills

Cultural competence

EHR navigation

Education

Bachelor's Degree in Nursing (BSN) preferred

Tools

EHR systems

Clinical software

Job description

Job Summary

The Registered Nurse (RN) for Stars Quality plays a critical role in promoting, protecting, and improving the health of the health plan's members. This role involves developing and implementing initiatives to manage chronic conditions, improve preventive care screenings, and closing gaps in care, directly impacting the plan's quality performance metrics, particularly the Medicare Advantage STARS ratings. The RN collaborates with interdisciplinary teams, providers, and community resources to ensure members receive the most appropriate, high-quality, and cost-effective care.

The Registered Nurse (RN) for Stars Quality plays a critical role in promoting, protecting, and improving the health of the health plan's members. This role involves developing and implementing initiatives to manage chronic conditions, improve preventive care screenings, and closing gaps in care, directly impacting the plan's quality performance metrics, particularly the Medicare Advantage STARS ratings. The RN collaborates with interdisciplinary teams, providers, and community resources to ensure members receive the most appropriate, high-quality, and cost-effective care.

Key Responsibilities

• Monitor and track member data to identify and close gaps in care for key preventive screenings and chronic disease management measures (HEDIS/STARS).
• Coordinate services across the continuum of care, including post-discharge follow-ups, to ensure seamless transitions and reduce preventable hospital admissions and readmissions.
• Engage members through various methods (phone, secure messaging). To promote self-management goals, encourage adherence to treatment plans, and connect them with relevant community resources.
• Utilize electronic health records (EHR) and population health management systems to accurately document all patient interactions, monitor outcomes, analyze data trends for populations, and participate in quality improvement activities.
• Assist in educating providers and office staff within the network regarding population health initiatives, HEDIS/STARS measures, and best practices for improving quality outcomes.
• Serve as a patient advocate, helping members navigate the healthcare system and collaborating with social/ behavioral health workers, community organizations, and other healthcare professionals to address social determinants of health and reduce disparities.
• Perform other job-related duties as assigned.

Qualifications

• Strong clinical assessment, critical thinking, and problem-solving skills.
• Excellent communication (verbal and written), interpersonal, and patient engagement skills, including cultural competence.
• Proficiency in navigating EHR systems and other clinical software platforms.
• Ability to work independently, prioritize effectively, and collaborate within a multidisciplinary team.
• Ability to converse and write fluently in English.

Education/Experience

• Graduate from an accredited School of Nursing. A Bachelor's Degree in Nursing (BSN) is preferred.
• 2-3 years’ of clinical nursing experience (e.g., acute care, community health, or case management).
• Experience in a managed care environment or value-based care organization strongly preferred.
• Knowledge of HEDIS measures, STARS program requirements, or other quality metrics is a significant plus.
• Active, unrestricted Registered Nurse (RN) license in the state of employment or a compact state license.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin