The Quality Nurse Auditor (QNA) is responsible, as part of the Landmark Health team, for completing chart audits associated with CCM (Complex Case Management), quality assurance related to CCM Delegation, and supporting team members with training related to CCM processes. The Quality Nurse Auditor is also responsible to conduct and report other regulatory compliance audits, performance audits, outcomes audits as assigned. The Quality Nurse Auditor completes independent assessments of patient charts in accordance with policies and procedures, clinical guidelines, applicable regulatory standards and client requirements. The Quality Nurse Auditor works closely with their assigned Market Leadership to assist with training needs and improvement activities identified through the audit and corrective action process to ensure the Market is in the position to meet all requirements internal and external. The QNA will assist with the training of new NCMs and provide feedback to the Market Leadership team with regards to progress and support the team with maintaining current knowledge across all team members with regards to updates to the expectations, regulations or processes.
The QNA uses assessment and evaluation skills to conduct delegation, regulatory and performance audits and manages the corrective/improvement process to insure compliance. Strong CM knowledge and experience is necessary.
Responsibilities Conduct Complex Care Management chart audits within OnSpringProvide real time feedback as to open issues with records to meet complianceProvide orientation/training to new NCMs to set a strong foundationWork closely with assigned Market Leadership to assess ongoing training needs through regular communication Conduct the data collection for regulatory audits such as:Notice of Privacy Practices, Release of Medical Records, Authorized Representative (list is not all inclusive) Conduct the data collection for performance and outcomes audits, such as:Medical Records Audits, Guideline Compliance, Outcomes Management audits, Data Integrity and Outcomes Audits (list is not all inclusive) Track all CCM referrals including key indicators vs. timeline (i.e. HFA, HSA and care plans quality) Conduct CCM delegation training for new hires and ongoing training based on audit results and team member needs. Independently use discretion and judgment to evaluate objective and subjective clinical documentation to assess performance of nursing skill and the skills of other allied health professionals, based on Regulatory Standards, Health Plan and contractual obligations, and company policy Applies advanced knowledge to conduct multi-specialty subjective assessments to evaluate the skills of nurses and other allied health professionals Consults with the assigned Market Leadership to collaborate on subjective assessments to ensure consistency of feedback related to complex, high risk cases Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow policies, State regulations and Accreditation standards Collate all data available to illustrate a full picture of Company, Market and individual staff members performance Generate reports /findings of reviews: in a clear, concise manner that is understandable and actionable Provide consultation to support staff coaching and development efforts Manual Our Workflow Assist, as needed, to determine areas that require immediate remediation and assist employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and member engagement Help Process Identifies tracks and records best practices, sharing the specifics with Market leadership Participate in and conduct training and performance improvement related projects to support staff development as well as assist with the training of new employees The Clinical Nurse Auditor will highlight key findings for implementation of performance improvement plans when necessary Participate in NCQA accreditation activities Work with colleagues across Market units to ensure that process and procedural changes are reflected in staff member documentation such as job aids and policies Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner Ability to work and interact with professionals as part of an interdisciplinary team Self-motivated, flexible person who can flourish in an office setting with colleagues as well as in a self-structured independent setting Ability to accept constructive feedback for continual improvement Ability to add to a team atmosphere where a team approach is highlighted and valued Thrives in a process based transactional work environment Quickly adapt to new technology Must stay abreast of all customer specific details, to ensure high quality customer service Accept additional assignments willingly Basic computer knowledge such as Word and Excel. Strong administrative, clerical and organizational skills. Excellent customer service and follow-up skills Strong attention to detail
Qualifications Valid nursing license in good standing (RN with BSN preferred) 2 or more years of clinical audit experience preferred Ability to obtain license in the states for which you are assigned as required IRR (inter-rater reliability) experience preferred Knowledge of CCM (certified CCM preferred) NCQA knowledge and experience preferred Quality Assurance/Auditing experience preferred Experience in case management, assessments and care planning required CCM/Delegation auditor experience preferred HEDIS familiarity preferred General knowledge of Audit functions, purpose and reporting Knowledge and/or experience with Regulatory Audits Certified Auditor(Landmark will do the education and certification)