RN Clinical Operations Quality Assurance Improvement Case Management

About the Job

General Summary of Position

The Clinical Operations Quality Assurance and Improvement RN leads the design implementation and continuous advancement of quality training auditing compliance and performance improvement programs across Clinical Operations for MedStar Family Choice DC and Maryland. This role serves as the clinical subject matter expert for documentation integrity NCQA standards utilization management case management regulatory compliance and operational best practices.In partnership with the Vice President of Clinical Operations and department leaders the incumbent develops and implements standardized processes training programs competency validation frameworks and quality monitoring activities that promote consistent clinical practice regulatory adherence and operational excellence. Through ongoing audits data analysis performance monitoring and targeted improvement initiatives this role identifies opportunities to enhance documentation quality workforce competency process effectiveness member outcomes and organizational performance.The Clinical Operations Quality Assurance and Improvement RN plays a critical role in accreditation readiness regulatory audits system implementations and enterprise-wide clinical improvement initiatives while fostering a culture of accountability continuous learning quality and excellence.

Primary Duties and Responsibilities

• CLINICAL OPERATIONS:Demonstrates behaviors consistent with MedStar Family Choice's mission vision values and member/enrollee-centered care philosophy.Ensures compliance with organizational policies accreditation standards contractual obligations and regulatory requirements.Maintains expertise in MedStar Family Choice programs benefits clinical workflows and operational processes.Partners with Clinical Operations leadership to enhance performance across Care Coordination Case Management Utilization Management and Population Health programs.
• TRAINING & EDUCATION:Develops implements and maintains standardized onboarding and orientation programs for Clinical Operations staff.Maintains and updates training materials workflows job aids competency assessments and educational resources.Delivers instructor-led virtual and individualized training and education sessions.Coordinates annual education plans mandatory training requirements and competency validation activities.Partners with leaders and preceptors to ensure successful transition from onboarding to operational practice.Provides coaching feedback and targeted education based on audit findings performance trends and operational needs.Develops and implements remediation plans to address identified competency gaps.Maintains centralized training documentation curricula schedules and competency records.Evaluates training effectiveness through performance metrics audit results and participant feedback.
• QUALITY ASSURANCE & AUDITING:Administers and maintains the Clinical Operations Audit Program including audit tools methodologies reporting and data validation processes.Conducts routine audits of clinical documentation case management utilization management and other Clinical Operations functions.Evaluates compliance with: oNCQA standardsoCMS requirementsoDHCF contractual obligationsoMaryland Department of Health and COMAR regulationsoOrganizational policies and proceduresoClinical documentation standardsoOther applicable regulatory requirementsPerforms Utilization Management audits to assess appropriate application of InterQual® criteria and clinical decision-making.Leads Inter-Rater Reliability (IRR) testing and validation activities.Monitors documentation quality timeliness accuracy consistency and regulatory compliance.Identifies trends risks gaps and opportunities for quality and process improvement.Prepares audit reports findings recommendations and corrective action plans.Monitors corrective actions and validate sustained compliance and performance improvement.
• QUALITY IMPROVEMENT:Analyzes clinical and operational performance data to identify improvement opportunities.Develops and implements quality improvement initiatives based on audit findings regulatory requirements and operational performance.Collaborates with leadership to design and implement workflow and process improvements.Establishes measurable performance improvement goals and success metrics.Presents findings recommendations and outcomes to leadership and quality committees. Supports process redesign and continuous quality improvement initiatives across Clinical Operations.
• REGULATORY & ACCREDITATION READINESS:Leads readiness activities for NCQA accreditation regulatory reviews and external audits.Maintains validated audit tools compliance monitoring processes and supporting documentation.Coordinates mock audits readiness assessments and corrective action activities.Ensures clinical operations workflows training programs and documentation practices remain aligned with evolving regulatory and accreditation requirements.
• DATA ANALYTICS & REPORTING:Develops and maintains reports dashboards and performance metrics related to: oAudit outcomesoDocumentation qualityoStaff competencyoTraining completionoPerformance trendsoRegulatory complianceAnalyzes operational and clinical data to identify trends risks and improvement opportunities.Prepares executive summaries and present actionable recommendations to leadership. Evaluates the effectiveness of education auditing and performance improvement interventions.
• PROJECT MANAGEMENT:Participates in and supports organizational initiatives impacting Clinical Operations.Assists with implementation of new systems workflows regulatory requirements and process improvements.Gathers and documents business requirements related to clinical operational processes.Assesses operational impacts and readiness for new initiatives and system changes. Collaborates with multidisciplinary teams to improve efficiency quality and regulatory compliance.
• COLLABORATION & LEADERSHIP:Serves as a clinical quality compliance and training resource for leadership and frontline staff.Collaborates with Clinical Operations Quality Compliance Information Systems and other departments to support organizational goals.Participates in committees work groups and organizational meetings as assigned.Promotes a culture of accountability continuous learning quality improvement and operational excellence.

Minimal Qualifications

Education

• Bachelor's degree in Nursing required
• Master's degree Healthcare or Nursing preferred

Experience

• 3-4 years Case Management and utilization review experience required and
• 3-4 years Clinical training auditing quality improvement staff development and/or regulatory compliance experience. required and
• 1-2 years Experience in NCQA accreditation managed care organization / health plan. preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia and Maryland Upon Hire required and
• CCM - Certified Case Manager Active certification in good standing within 2 years preferred

Knowledge Skills and Abilities

• Skilled in planning executing and evaluating educational gaps and developing performance improvement initiatives
• Possess exceptional interpersonal and communication skills
• Knowledge of current trends in healthcare delivery and Case Management / utilization review criteria
• Ability to use computer to enter and retrieve data.
• Ability to create edit and analyze (Word Excel and PowerPoint)
• Demonstrate proficiency with all MedStar Family Choice software systems that support the clinical operation.
• Possess exceptional interpersonal and communication skills.

This position has a hiring range of

USD $89,065.00 - USD $162,801.00 /Yr.