The Quality Care Coordinator develops, implements and provides ongoing monitoring of intervention plans and quality gap closure. The role goal is to reduce medical costs and improve quality ratings through member and/or provider engagement, internal quality process improvement work, and coordination of overall clinical intervention strategies. The Quality Care Coordinator conducts HEDIS and year-round medical record reviews and is responsible for ensuring that Network Health meets all OCI, CMS and NCQA quality requirements.
Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha is required occasionally for the position, including on first day.
Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday
Check out our 2025 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.
Job Responsibilities:
- Provide direct outreach to members and/or providers in order to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars and NCQA
- Create written materials for members, physicians, and other customers in formats such as newsletters, brochures, self-care materials, educational handouts, letters and telephone scripts
- Responsible for development and coordination of member centric programs in alignment with industry and regulatory standards
- Evaluate utilization patterns, medical records and other metrics to monitor quality and efficiency results
- Provide clinical support for the appeals and grievance department and quality of care complaint process, preparing cases for medical director review when needed
- Identify opportunities for improvement and implement clinical interventions
- Prepare and/or deliver presentations for Quality Management committee, clinic or provider education, and system-wide committees as needed
- Coordinate, monitor, and document quality interventions and care management programs with goal of effectiveness that promotes value added care and service
- Collaborate closely with secondary providers (Breathe at Ease, Home Telemetry, Diabetes programs) to coordinate services for members
- Function as a liaison when needed for family, member and provider to communicate any current of potential issues
- Develop review and revise department policies and procedures including preventive services requirements.
- Provide recommendations for preventive services medicine and evidence based clinical guidelines, seek approval and monitor for updates or relevant changes as assigned.
- Research, submit and evaluate quality improvement projects regulated by CMS as assigned.
- Implement systems of care that facilitate close monitoring of members to promote early intervention.
- Assist with updating and maintaining Clinical Integration (CI) manual and documentation related to CI including reports
Job Requirements:
- Bachelor of Science in Nursing, preferred
- Associate Degree in Nursing, required
- Current registered nurse licensure in Wisconsin required
- Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required
- Experience in basic data analysis, quality improvement, or HEDIS medical record review, preventive care, or health plan experience preferred
Network Health is an Equal Opportunity Employer