RN Clinical Quality & HEDIS Specialist

Peak Health; Core (WV); On-site; USD 85,000 - 110,000; Full time

Job summary

PHH Peak Health Holdings seeks a Clinical Quality Specialist to join the quality team. You will oversee CQI activities, ensure regulatory compliance, and support HEDIS through medical record retrieval and provider collaboration.

Strong CMS/NCQA/HEDIS expertise, data-driven mindset, and ability to drive performance improvement across plans and providers are essential. Remote work with occasional on-site visits in the U.S.

Qualifications

• RN license in the state of service or multi-state eNLC and 4 years healthcare clinical experience.
• Or Bachelor's degree with 6 years healthcare quality management or PI experience.
• Knowledge of CMS guidelines, NCQA/URAC and HEDIS/Stars.

Responsibilities

• Plan, design, implement, and maintain a CQI program via HEDIS tracking and analysis.
• Lead HEDIS/Stars improvement activities including chart reviews and interventions.
• Prepare annual QI evaluation reports and program documents.
• Review medical records to ensure quality care is provided.
• Ensure compliance with workflows, policies, and regulatory standards.
• Investigate quality of care issues and evaluate reports.
• Participate in quality committee and develop annual work plans.

Skills

CMS knowledge

PIPs

Data analysis

MS Office

Communication

Medicare experience

Remote work

Education

Registered Nurse license (state) or eNLC

Bachelor's degree in healthcare or related field

BSN/ASN (preferred)

Tools

Microsoft Office

HEDIS/NCQA tooling

Job description

PHH Peak Health Holdings seeks a Clinical Quality Specialist to join the quality team. You will oversee CQI activities, ensure regulatory compliance, and support HEDIS through medical record retrieval and provider collaboration.

Strong CMS/NCQA/HEDIS expertise, data-driven mindset, and ability to drive performance improvement across plans and providers are essential. Remote work with occasional on-site visits in the U.S.