Health Plan Quality Improvement Coordinator

Sentara Health Plans in Virginia Beach is looking to hire a Remote Health Plan Quality Improvement Coordinator.

This is a remote position; however, candidates must reside in Virginia North Carolina or Florida. 

The Quality Improvement (QI) Coordinator is responsible for coordinating and conducting Quality Improvement activities related to Critical Incident investigations, Quality of Care (QOC) and Quality of Service (QOS) reviews, and member safety oversight in accordance with Virginia Medicaid (DMAS) requirements, CMS regulations, and Sentara Health Plans (SHP) policies and procedures.

This role supports the Quality Improvement Program by ensuring timely identification, investigation, documentation, analysis, and resolution of Critical Incidents and quality concerns, while promoting continuous quality improvement and optimal care outcomes for SHP members.

Essential Duties and Responsibilities

Critical Incident Management

• Receives, reviews, and coordinates Critical Incident reports, including but not limited to abuse, neglect, exploitation, sentinel events, mortality reviews, and serious quality of care concerns, in accordance with DMAS and CMS requirements.
• Ensures timely reporting, investigation, follow-up, and closure of Critical Incidents within required regulatory timeframes.
• Conducts comprehensive reviews of medicais records, incident reports, and supporting documentation to assess appropriateness of care, services rendered, and member safety outcomes.
• Identifies trends, root causes, and systemic issues contributing to Critical Incidents and communicates findings to leadership.

Quality of Care and Quality of Service Reviews

• Coordinates and performs Quality of Care (QOC) and Quality of Service (QOS) investigations, including grievances and referrals from internal and external stakeholders.
• Applies established clinical and quality standards to determine quality determinations and facilitate corrective actions per the Medical Directors’ recommendations, when indicated.
• Drafts clear, concise investigative summaries, determinations, and correspondence for internal review, regulatory reporting, and provider communication.

Regulatory Compliance and Documentation

• Ensures compliance with DMAS contract requirements, CMS regulations (including 42 CFR §438), and SHP Quality Program policies.
• Maintains accurate documentation and case tracking in designated systems (e.g., quality tracking tools, databases, and reports).
• Prepares data, reports, and supporting documentation for regulatory audits, reviews, and oversight activities, including DMAS, CMS, and external quality review organizations.

Performance Improvement and Reporting

• Supports Quality Improvement initiatives by contributing to performance monitoring, trend analysis, and targeted improvement activities related to member safety and quality outcomes.
• Assists with the development and monitoring of Corrective Action Plans (CAPs) and follow-up activities to ensure sustained improvement.
• Participates in Quality Committees, workgroups, and interdisciplinary meetings as assigned.

Collaboration and Communication

• Collaborates with internal departments including Care Management, Medical Directors, Behavioral Health, Compliance, and Provider Relations.
• Coordinates with external stakeholders such as providers, facilities, and community agencies as needed to support investigations and quality improvement efforts.
• Provides education and guidance to staff and providers related to Critical Incident reporting requirements and quality expectations.

Core Competencies

• Attention to detail and regulatory accuracy
• Written and verbal communication
• Critical thinking and root cause analysis
• Time management and prioritization
• Collaboration and professionalism

Education 

• BSN preferred

• Associate’s degree (Required) or 

• LPN Diploma may be accepted in lieu of associate’s degree 

Certification:

• Registered Nurse preferred.

Experience 

• 3 years of quality improvement experience (Required) 

• 3 years of regulatory and accreditation (Required) 

Keywords: Talroo-Allied Health, Quality Improvement, NCQA, MCHIP, DMAS, CMS