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

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.

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.