Quality Improvement Nurse

JSG is seeking two Quality Improvement HEDIS Nurse Overreader's to support our client on a contractual basis in South San Francisco. This role involves assessing the effectiveness of care environments in meeting regulatory standards and ensuring evidence-based care. The QI Nurse will engage in a variety of tasks, including data collection, medical record review, regulatory compliance checks, and quality improvement activities, with the primary goal of optimizing member care outcomes.

Contract I Hybrid

Duties:

- Conduct Facility Site Reviews (FSRs), Physical Accessibility Reviews (PARs), and Medical Record Reviews (MRRs) using state-approved tools.

- Assess compliance with regulatory requirements through clinical knowledge and judgment.

- Document, report, and communicate findings as required; issue and monitor Corrective Action Plans (CAPs).

- Conduct pre-contractual compliance reviews with potential providers.

- Maintain comprehensive knowledge of Department of Health Care Services (DHCS) site review standards.

- Ensure accurate data collection, abstraction, and overreading of HEDIS records.

- Maintain compliance with National Committee for Quality Assurance (NCQA) standards.

- Manage and analyze quality-related data effectively.

- Track, trend, and report on outcomes for continued improvement.

- Develop and implement quality improvement plans.

- Respond promptly and professionally to internal and external inquiries.

- Ensure clear and timely communication with internal audiences, external stakeholders, and regulatory bodies.

- Keep accurate records of all assessments and reviews.

Qualifications:

- Current nursing license and experience in quality improvement and HEDIS processes.

- Strong clinical knowledge and judgment.

- Excellent organizational and communication skills.

- Proficient in data management and analyzing clinical outcomes.

- Familiarity with regulatory and NCQA standards

** Johnson Service Group (JSG) is an Equal Opportunity Employer. JSG provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, marital status, protected veteran status, or any other characteristic protected by law.