The Quality Management Clinical Nurse Specialist is responsible for conducting comprehensive facility site reviews (FSRs) to ensure compliance with healthcare standards and regulations. This role involves evaluation clinical practices, identifying areas for improvement, and implementing quality improvement initiatives to enhance patient care and safety. In this role, you will supports all Medical Group Health Education & Disease Management Programs utilizing established interventions, performing necessary surveys acting as the primary liaison between providers and office staff and Health Plans to facilitate appropriate Health Education opportunities. Additionally, you will performs HEDIS related activities, Pay for Performance activities, Provider Access and Availability Surveys (PAAS), investigates and resolves access-related patient issues, and develops QI reports and action plans, as necessary. 

Key responsibilities include:

• Travel to various clinic sites and schedule and conduct medical record and facility site audits
• Conduct thorough facility site reviews and medical record audits, including inspections of clinical areas, patient care practices, and administrative processes
• Review medical records of services in preparation for health plan and/or regulatory audits for medical appropriateness by using established clinical protocols and health plan resource tools
• Assess compliance with healthcare regulations, accreditation standards, and organizational policies
• Extrapolate and prepare a detailed, organized analysis of the essential information gathered to address facility site reviews and medical record audits
• Prepare detailed reports on findings from site reviews and present recommendations to management
• Identify areas for improvement and develop action plans to address deficiencies. Develop corrective action plans as needed conducting appropriate follow up and provide related reports
• Collaborate with healthcare providers and administrative staff to implement quality improvement initiatives
• Provide education and training to internal staff on quality management practices and regulatory requirements
• Assist in QM Department projects including but not limited to HEDIS/Pay for Performance, clinical studies and access surveys producing charts, graphs, and reports to demonstrate results and outcomes
• Initiate and maintain QM activities required for the credentialing and re-credentialing process
• Attend and participate in QM meetings preparing agendas, materials, minutes, and action follow-ups in a timely manner