The Quality Care Coordinator develops, implements and provides ongoing
monitoring of intervention plans and quality gap closure. The role goal is to
reduce medical costs and improve quality ratings through member and/or provider
engagement, internal quality process improvement work, and coordination of
overall clinical intervention strategies. The Quality Care Coordinator conducts
HEDIS and year-round medical record reviews and is responsible for ensuring that
Network Health meets all OCI, CMS and NCQA quality requirements.
Location: Candidates must reside in the state of Wisconsin for
consideration. This position is eligible to work at your home office (reliable
internet is required). Travel to the corporate office in Menasha is required
occasionally for the position, including on first day.
Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday
Check out our 2025 Community Report
[https://www.youtube.com/watch?v=Oea3uHW0EV0]https://networkhealth.com/__assets/pdf/2025_annual_report.pdf to
learn a little more about the difference our employees make in the communities
we live and work in. As an employee, you will have the opportunity to work hard
and have fun while getting paid to volunteer in your local neighborhood. You
too, can be part of the team and making a difference. Apply to this position to
learn more about our team.
Job Responsibilities:
Provide direct outreach to members and/or providers in order to close quality
gaps and maintain or exceed expected population health outcomes per HEDIS,
Stars and NCQA
Create written materials for members, physicians, and other customers in
formats such as newsletters, brochures, self-care materials, educational
handouts, letters and telephone scripts
Responsible for development and coordination of member centric programs in
alignment with industry and regulatory standards
Evaluate utilization patterns, medical records and other metrics to monitor
quality and efficiency results
Provide clinical support for the appeals and grievance department and quality
of care complaint process, preparing cases for medical director review when
needed
Identify opportunities for improvement and implement clinical interventions
Prepare and/or deliver presentations for Quality Management committee, clinic
or provider education, and system-wide committees as needed
Coordinate, monitor, and document quality interventions and care management
programs with goal of effectiveness that promotes value added care and
service
Collaborate closely with secondary providers (Breathe at Ease, Home
Telemetry, Diabetes programs) to coordinate services for members
Function as a liaison when needed for family, member and provider to
communicate any current of potential issues
Develop review and revise department policies and procedures including
preventive services requirements.
Provide recommendations for preventive services medicine and evidence based
clinical guidelines, seek approval and monitor for updates or relevant
changes as assigned.
Research, submit and evaluate quality improvement projects regulated by CMS
as assigned.
Implement systems of care that facilitate close monitoring of members to
promote early intervention.
Assist with updating and maintaining Clinical Integration (CI) manual and
documentation related to CI including reports
Job Requirements:
Bachelor of Science in Nursing, preferred
Associate Degree in Nursing, required
Current registered nurse licensure in Wisconsin required
Minimum of four (4) years clinical health care experience as a Registered
Nurse (RN) required
Experience in basic data analysis, quality improvement, or HEDIS medical
record review, preventive care, or health plan experience preferred
Network Health is an Equal Opportunity Employer