Apply on Employer Site

VNS Health · 2 weeks ago

Quality Reviewer/Auditor

New York, NY

Full-time

Onsite

Mid Level

$93K/yr - $117K/yr

4+ years exp

VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. The Quality Reviewer/Auditor provides consultative services and manages quality improvement activities to enhance patient care and compliance with regulatory standards.

CharityHealth CareHome Health CareNon Profit

H1B Sponsor Likely

Responsibilities

Collaborates with clinical management to identify, develop and implement quality improvement standards and criteria that meet program goals. Evaluates effectiveness of standards and recommends changes, as needed

Ensures Quality Improvement programs are aligned with CMS Triple Aim framework: improving the patient’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare

Establishes and communicates protocols and standards of care for a cultural and demographic diverse patient/member population; provides intervention guidelines based on these population health needs

Coaches and facilitates performance improvement activities designed to help teams and programs meet and exceed quality scorecard indicators. Instructs management and staff in the meaning and use of data for the purpose of assessing and improving quality

Participates in the development of standards and criteria for monitoring compliance with Federal and State regulatory requirements and VNS Health Plans performance standards of care. Develops performance measures and data collection instruments

Facilitates quality assurance and utilization review activities with interdisciplinary teams on ways to improve and positively affect the care that is provided to patients/members. Reviews and analyzes changes in the health status and outcomes of patients/members utilizing outcomes data. Consults and collaborates with clinical staff to identify trends and opportunities for improvement in health status and outcomes

Collaborates with operations management in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies

Conducts audits of patient/member case records. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology

Collaborates with operations management to assure compliance with CMS and DOH requirements. Coaches, facilitates and monitors continuous improvement to attain strategic quality objectives and industry benchmarks for patient/member outcomes, satisfaction, cost and regulatory requirements

Collaborates with Education department in the development of and implementation of quality related training programs

Keeps informed of the latest internal and external issues and trends in utilization and quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies and procedures to address these trends

Performs onsite medical record reviews for HEDIS or other related compliance or quality improvement initiatives

Participates in the development and implementation of quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, Quality Scorecard, IPRO Projects, and CMS Quality Projects

For RN Quality Reviewer only: Provides clinical support in the Grievance and Appeals process

Follows-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively

Investigates patient/member related complaints and quality of care (QOC) issues, incidents, and serious adverse reportable events in collaboration with internal staff and providers. Performs utilization and quality assessment review; identifies and analyzes results; prepares investigation summary report; and creates/implements corrective action plan as appropriate. Provides education about identified quality trends, outcomes of reviews and new requirements

For RN Coder only: Audit Medical Record documentation for in home assessments and claims/encounters from various provider disciplines to ensure documentation and coding accuracy. Perform Risk Adjustment data validation for Medicare HCC Risks

Participates in special projects and performs other duties as assigned

Qualification

Registered Nurse LicenseQuality ImprovementStatistical AnalysisHealth Care Delivery SystemsPerformance Improvement ToolsCommunication Skills

Required

License and current registration to practice as a registered professional nurse preferably in New York State required or

License and current registration to practice as a registered professional nurse preferably in New Jersey State required

Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs

Bachelor's Degree in health care administration, human services or business administration or related discipline or the equivalent work experience in a related professional field required

Minimum of four years clinical experience in a health care setting, including at least two years with a focus on quality improvement and measurement or related experience required

Knowledge of health care delivery systems, patient care, care coordination, and clinical processes required

Ability to perform statistical/quantitative analysis required

Excellent oral, written and interpersonal communication skills required

Preferred

Knowledge of basic Performance Improvement tools and methodologies

Benefits

Referral bonus opportunities

Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays

Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability

Employer-matched retirement saving funds

Personal and financial wellness programs

Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care

Generous tuition reimbursement for qualifying degrees

Opportunities for professional growth and career advancement

Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

Company

VNS Health

Glassdoor3.5

VNS Health provides home care, hospice care, and behavioral health services.

Founded in 1893

New York, New York, USA

10001+ employees

https://www.vnshealth.org

H1B Sponsorship

VNS Health has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (7)

2024 (7)

2023 (9)

2022 (8)

2021 (4)

2020 (11)