Senior Quality Improvement Specialist, Clinical (Registered Nurse)

Overview
Supports interdepartmental Quality Improvement (QI) initiatives focused on promoting high-quality, safe, and equitable member care. Serves as a clinical and operational resource to QI committees, workgroups, and leadership. Analyzes outcomes, HEDIS/CAHPS/Stars performance, and trend data to identify opportunities for improvement in care coordination, quality, and member experience. Designs, implements, and evaluates QI programs aligned with DOH, CMS, and NCQA standards. Collaborates across departments—including Care Management, Utilization Management, Provider Relations, Compliance, and Analytics—to sustain continuous improvement, advance health equity, and ensure regulatory readiness.

What You Will Do

Conducts clinical assessment including and not limited to, medication reconciliations, post-discharge transitions of care assessment and follow-up post emergency department assessment.

Collaborates across departments to ensure compliance with DOH, CMS, and NCQA requirements. Coaches teams in applying continuous improvement methodologies (PDSA, LEAN, RCA) to achieve strategic objectives and national benchmarks for quality, satisfaction, and cost. Partners with analytics and program teams to identify trends and address performance gaps.

Performs clinical reviews with network providers to validate diagnoses, address care gaps, and support accurate HEDIS/QARR documentation. Collaborates with providers to improve adherence to evidence-based care and quality measures.

Participates in multidisciplinary QI teams and committees to support design, implementation, and evaluation of improvement initiatives related to clinical performance, documentation, and regulatory compliance. Supports development of annual QI work plan, program evaluation, and performance reporting.

Supports value-based programs through data review, gap identification, and provider feedback.

Performs medical record audits to evaluate adherence to documentation, coding, and quality standards. Provides education, feedback, and guidance to PCPs on VNS Health Medical Record Documentation Standards.

Conducts audits of patient care records to monitor care quality and documentation accuracy.. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient care review, including the design, testing and evaluation of the review methodology.

Performs utilization and quality assessment reviews to maintain compliance with Federal and State regulatory requirements. Identifies & analyzes results to inform the development of correction plans.

Collaborates with management to develop measurable action plans based on root-cause analysis, outcome trends, and survey results (HEDIS, CAHPS, Stars). Presents recommendations to QI committees and leadership to drive improvement and accountability.

Participates in the preparation for and assists with site visits of external providers for the purpose of regulatory quality compliance.

Develops and disseminates training materials, clinical guidelines, and quality protocols to promote consistent evidence-based care across provider networks and internal teams. Provides education sessions and quality coaching as needed.

Conducts follow-up reviews and reassessments to ensure corrective actions for regulatory findings, complaints, or incidents are implemented effectively and sustained over time. Documents progress and escalates unresolved issues as appropriate.

Develops, maintains, and updates QI policies and procedures aligned with evolving regulatory and industry standards. Collaborates with analytics to collect, interpret, and share performance data with internal teams to drive transparency and accountability.

Participates in special projects and performs other duties as assigned.

Qualifications
Licenses and Certifications:
License and current registration to practice as a Registered Professional Nurse in New York State or New Jersey required

Education:

Bachelor's Degree Nursing required

Work Experience:

Minimum of five years experience in a health plan or health care setting required

Minimum of four years quality improvement experience required

Minimum of two year experience, quality management, practice improvement and compliance required

Demonstrated experience leading or facilitating cross-functional quality initiatives required

Excellent oral, written and interpersonal communication skills, including group facilitation skills required

Knowledge of basic Performance Improvement tools and methodologies (e.g., PDSA, LEAN, Six Sigma). preferred

Experience applying data analysis to clinical and operational improvement strongly desired. preferred