Quality Improvement Nurse - Part Time

AlohaCare; Honolulu (HI); On-site; USD 78,000 - 85,000; Full time

Benefits offered by this job

Low-cost medical, dental, drug and vis

Paid time-off

401k employer contribution

Referral bonus

Pretax transportation and parking

Job summary

AlohaCare seeks a Quality Improvement Nurse to advance our quality strategy by collaborating with providers, members, and internal teams to improve outcomes and close care gaps. You will support HEDIS, Medicare Stars, and pay-for-performance initiatives, coordinating interventions for targeted measures and ensuring timely preventive and chronic care follow-up.

Responsibilities include outreach to members and providers, review of data, education on care gap closure, and documentation of outcomes.

Qualifications

• Minimum of 2 years of clinical experience.
• Ability to assess, evaluate and interpret clinical information.
• Familiarity with healthcare regulations and accreditation standards.
• Knowledge of preventive care, chronic condition management, quality improvement principles, and managed care operations.
• Familiarity with HEDIS, Medicare Stars, Med-QUEST Pay for Performance, NCQA, CMS requirements, or related quality reporting programs.
• Ability to conduct professional member and provider outreach using strong telephonic, written, and interpersonal communication skills.
• Able to work independently with minimal supervision.
• Excellent time management and organizational skills; dependable and motivated.
• Basic computer knowledge; data analysis and competence with spreadsheets/databases.

Responsibilities

• Coordinate with providers and members to address targeted quality measures and outreach opportunities.
• Review gap-in-care reports, clinical data, claims, and other data to identify outreach priorities.
• Support scheduling, documentation, and data capture to close quality gaps with provider offices.
• Educate members on preventive care and follow-up needs and available resources.
• Collaborate with Quality Reporting, Population Health Management, Health Services, Pharmacy, Provider Relations, and Compliance teams on quality initiatives.
• Track outreach activities and barriers to care, and report outcomes to Quality leadership.
• Assist with provider education related to quality measure requirements and documentation expectations.
• Support medical record review, data collection, and validation for quality reporting.
• Participate in quality improvement projects, committees, and outreach campaigns.
• Prepare updates and summaries on outreach progress and opportunities for improvement.

Skills

Clinical experience

Assessment & interpretation

Regulatory knowledge

Preventive care knowledge

Quality improvement principles

HEDIS/Medicare Stars knowledge

Care gap outreach

Independent work

Time management

Basic computing & data tools

Job description

Are you ready for new challenges and new opportunities?

Join our team!

Current job opportunities are posted here as they become available.

Subscribe to our RSS feeds to receive instant updates as new positions become available.

AlohaCare’s leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

The Opportunity:

The Quality Improvement Nurse supports AlohaCare’s quality strategy by working directly with providers, members, and internal teams to improve quality outcomes and close gaps in care. This role performs provider and member outreach, coordinates interventions for targeted quality measures, supports HEDIS, Medicare Stars, Med-QUEST Pay for Performance, population health, and other quality improvement initiatives, and helps ensure that members receive timely preventive, chronic condition, and follow-up care.

The Quality Improvement Nurse serves as a clinical resource for quality measure improvement activities, including outreach to members and providers, review of clinical information, coordination of services, education on care gap closure opportunities, and documentation of outreach outcomes. This position requires strong clinical judgment, communication skills, and the ability to work collaboratively across departments to improve member outcomes, quality scores, and regulatory performance.

• Coordinates with providers and members to address targeted quality measures, including but not limited to:
  • Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
  • Diabetes Care – Blood Sugar Controlled
  • Diabetes Care – Eye Exam
  • Kidney Health Evaluation for Patients with Diabetes
  • Controlling High Blood Pressure
  • Breast Cancer Screening
  • Colorectal Cancer Screening
  • Plan All-Cause Readmissions
  • Follow-Up After Hospitalization for Mental Illness
  • Prenatal and Postpartum Care
  • Well-Child Visits in the First 30 Months of Life
  • Child and Adolescent Well-Care Visits
  • Childhood Immunization Status
• Reviews member gap-in-care reports, clinical data, claims, supplemental data, and other available information to identify outreach priorities and intervention opportunities.
• Works with provider offices to support scheduling, documentation, medical record submission, supplemental data capture, and other activities needed to close quality gaps.
• Educates members on the importance of preventive care, chronic condition monitoring, follow-up care, and available health plan or community resources.
• Assists members in navigating care needs, including follow-up appointments, screenings, testing, immunizations, and services related to targeted quality measures.
• Collaborates with internal departments, including Quality Reporting, Population Health Management, Health Services, Pharmacy, Provider Relations, Grievance and Appeals, Compliance, and other teams to support quality improvement initiatives.
• Supports development and implementation of member- and provider-facing interventions aimed at improving HEDIS, Medicare Stars, Med-QUEST P4P, CAHPS, HOS, and other quality outcomes.
• Tracks outreach activities, member/provider responses, barriers to care, and gap closure outcomes in applicable systems, reports, and project trackers.
• Identifies barriers impacting gap closure, such as access to care, transportation, member engagement, provider documentation, or data limitations, and escalates trends to Quality leadership.
• Assists with provider education related to quality measure requirements, documentation expectations, coding considerations, supplemental data, and medical record submission.
• Supports medical record review, audit preparation, supplemental data collection, and validation activities related to quality reporting.
• Participates in quality improvement projects, performance improvement initiatives, committees, workgroups, and provider/member engagement campaigns.
• Prepares updates, reports, and summaries on outreach progress, quality measure performance, barriers, interventions, and opportunities for improvement.
• Assists with policies, procedures, desk-level procedures, workflows, scripts, training materials, and member/provider communications related to quality improvement and gaps in care.
• Supports compliance with NCQA, CMS, Med-QUEST, state, federal, and other regulatory or accreditation requirements related to quality improvement activities.
• Identifies and refers potential quality of care concerns, member grievances, suspected fraud, waste, or abuse, and other issues to the appropriate department.
• Maintains confidentiality of all members, provider, and Plan information in accordance with AlohaCare policies and applicable state and federal laws.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.
• Minimum of 2 years of clinical experience.
• Demonstrates ability for assessment, evaluation and interpretation of clinical information.
• Familiarity with healthcare regulations and accreditation standards.
• Knowledge of preventive care, chronic condition management, quality improvement principles, and managed care operations.
• Familiarity with HEDIS, Medicare Stars, Med-QUEST Pay for Performance, NCQA accreditation, CMS requirements, or other quality reporting programs preferred.
• Ability to conduct professional member and provider outreach using strong telephonic, written, and interpersonal communication skills.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.
• Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
• Basic computer knowledge, data analysis and competence with spreadsheet and database programs
• Experience in the operation of general office equipment to include PC, fax/copy machine and phone system.

Preferred Requirements:

• Minimum of 3 years of clinical experience; experience in an acute care setting desirable.
• Knowledge of QI/QA principles and methodology, health care/social research methodology, and ICD-9, ICD-10 and CPT codes desirable.
• Knowledge of HEDIS technical specifications, Medicare Stars, Med-QUEST P4P, CAHPS, HOS, NCQA, CMS, and/or other quality measure programs.
• Experience with provider outreach, member outreach, medical record review, supplemental data collection, or gaps-in-care closure initiatives.
• Knowledge of diabetes, hypertension, behavioral health follow-up, maternal/child health, preventive screenings, immunizations, and chronic disease management.
• Coding knowledge, CPC, CRC, Certified Diabetes Care and Education Specialist, or other relevant certification preferred.
• Previous experience in a managed care environment.

Mental, Physical and Environmental Demands:

• May require prolonged sitting - up to 4 hours.
• Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.
• Requires frequent travel throughout the state of Hawaii, including on Oahu and Neighbor Islands to conduct quality reviews or provider training. Own transportation is necessary to meet off-site travel requirements.

Salary Range: $78,000 - $85,000 annually

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.