Summary:  Responsible for participating in the quality management efforts including development, implementation, education, data collection, and analysis.

Duties and Responsibilities include the following.  Other duties may be assigned.

Develops, implements and monitors quality management policies and procedures for quality data collection and reporting on HEDIS and Gaps in Care Reports, UDS, Meaningful Use and PCMH measures.*
Identifies best clinical and business practices within the offices. Recommends standardized systems and develops a plan to implement and monitor systems within and across the organization.*
Helps quality improvement leader to plan, design, implement, and maintain a comprehensive medical practice continuous quality improvement (CQI) program to include utilization management and risk management.*

Assists in educating new staff, including physicians, about QI systems and requirements.*

Leads QI audits, prepares reports, and implements corrective action plans.*

Meets with internal and external audiences to identify and problem solve QI issues.*

Monitors medical practice efforts to ensure compliance with internal and external QI standards.*

Reviews medical records and other documentation to ensure quality care. Helps to prepare annual QI report.*

Coordinates the effort to extract/gather data and prepare reports to meet the requirements of NCQA and other regulatory/accrediting agencies, including patient satisfaction data.*

Evaluates variance and other data to identify QI opportunities and risk management issues.*

Monitors utilization and service quality through diagnosis-related group (DRG) review, HEDIS quality measures, payer/provider/patient satisfaction surveys.*

Supports and acts as liaisons with payers, providers, and patients and service as the primary patient information resource for payers.*

Conducts ongoing assessments of the existing eligibility and referrals, case management, disease management systems, and Quality Management programs within each practice. Provides objective evaluation and recommendations for those systems.*

Reviews existing practice information system capabilities for the tracking and monitoring of quality indicators. Makes the necessary adaptations for standardized reporting across all practices.*

Reports audits requiring clinical judgment and expertise to the Medical Director, QA/QI Committee and other entities, as assigned.*

Supervisory Responsibilities:  None


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Graduate of an approved school/training program for registered nurses or licensed practical nurses required. Minimum of two (2) years of direct patient care in an ambulatory health care setting. Must exhibit knowledge of medical records and analysis of processes of clinical care in addition to exhibiting knowledge of familiarity with the HEDIS/STAR measures and standards. At least two (2) years experience in managed care, or health care regulatory agency environment with a minimum of two (2) years experience in utilization management or quality improvement or chart abstraction for HEDIS/STAR, preferred.

Language Ability:

Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

Math Ability: 

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability:

Ability to apply commonsense understanding to carry out instructions furnished in written, oral, or diagram form.  Ability to deal with problems involving several concrete variables in standardized situations.

Certificates and Licenses:

Valid SC license for RN or LPN required

CPR certification required

Certified Professional in Healthcare Quality (CPHQ) preferred.

Knowledge, Skills and Other Abilities:
Basic nursing knowledge to include but not limited to preparing patients for physician visit, childhood and adult immunization requirements and routine protocols.

Ability to administer injections and perform laboratory tests

Ability to remove staple or sutures as authorized by the SC Board of Nursing Scope of Practice

Ability to develop and maintain personable yet professional relationship with patients and staff is required.

Knowledge of CQI principles, practices, methods, and tools.

Knowledge of computer applications related to QI, including spreadsheets.

Knowledge of medical records and clinical care processes.

Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry

Skill in effective education and facilitation of CQI efforts in medical practice.

Skill in application of analytical methods and statistical software by developing appropriate reports.

Skill in conducting QI checks of medical records and other clinical documentation and performing patient satisfaction surveys.

Ability to educate staff in both verbal and written form about QI in formal and informal settings.

Ability to interact effectively with health care team members.

Ability to analyze QI data and identify trends and corrective actions.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to use hands to finger, handle or feel objects, tools, or controls.  The employee is frequently required to stand, sit, reach with hands and arms, and talk or hear.  The employee is occasionally required to walk and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds.  Specific vision abilities required by this job include close vision.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Potential for rare exposure of blood borne disease (category II) and chemical hazards (category B)

The noise level in the work environment is usually moderate.


Tagged as: community health, healthcare, medical, nurse