Remote RN: Clinical Quality & HEDIS Improvement Specialist

WVU Medicine; West Virginia; On-site; USD 75,000 - 115,000; Full time

Job summary

PHH Peak Health Holdings is seeking a Clinical Quality Specialist to lead performance improvement initiatives, support HEDIS data collection and abstraction, and ensure regulatory and accreditation compliance across clinical programs. The role collaborates with the HEDIS Program Manager and Quality Manager to drive data-driven improvements and patient outcomes.

The position requires knowledge of CMS guidelines, NCQA/HEDIS, and experience with quality improvement projects.

Qualifications

• Knowledge of CMS regulatory and contractual documents including HEDIS/Stars
• Strong written and verbal communication skills
• Experience with data analysis and performance improvement methodologies
• Understanding of NCQA, URAC, and CMS guidelines
• Ability to work with large data sets and derive recommendations

Responsibilities

• Plan and execute CQI program with focus on HEDIS compliance rates
• Assist in preparing annual QI evaluation reports
• Review medical records to ensure quality of care
• Ensure processes meet regulatory and accreditation standards
• Investigate quality of care issues and assess risks
• Evaluate compliance with clinical quality requirements
• Participate in quality committees and workload planning

Skills

CMS knowledge

Excellent communication

Problem solving

Attention to detail

Microsoft Office

Medicare experience

Remote work ability

Education

Bachelor’s degree in healthcare or business-related field

BSN program enrollment allowed

Job description

PHH Peak Health Holdings is seeking a Clinical Quality Specialist to lead performance improvement initiatives, support HEDIS data collection and abstraction, and ensure regulatory and accreditation compliance across clinical programs. The role collaborates with the HEDIS Program Manager and Quality Manager to drive data-driven improvements and patient outcomes.

The position requires knowledge of CMS guidelines, NCQA/HEDIS, and experience with quality improvement projects.