Job Description

About us:

Fallon Health is a company that cares. We prioritize our membersalwaysmaking sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nations top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programsincluding Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly) in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

Under the general direction of the Senior Manager, Clinical Quality, the clinical nurse analyst is responsible for developing and implementing the assigned quality improvement initiatives, documentation of the processes, tracking of results and reporting outcomes. Other key responsibilities include medical record data abstraction for Healthcare Effectiveness Data and Information Set (HEDIS) and MassHealth Appendix Q review. The clinical nurse analyst will provide clinical expertise and support for departmental initiatives and the Quality Program structure as well as periodically assist in file review for NCQA accreditation.

Primary Job Responsibilities:

• Develop and implement assigned improvement strategies that support Fallons strategic goals.
• Implement, monitor, analyze and report quality improvement activities to ensure that Fallon members receive quality care in compliance with regulatory and contractual requirements.
• Reviews and abstracts clinical data from paper and electronic medical records for various needs and projects within the department, maintaining an inter-rater reliability score of 96% or above at all times.
• Particpates in the development of the annual Quality Work Plan and Work Plan Evaluation.
• Assist in the annual development of performance improvement initiatives as required.
• Maintains case review database and provides quarterly reporting.
• Participates in special projects as assigned, such as the NCQA Health Plan Accreditation, MassHealth Performance Improvement Plans (PIP), Compliance audits etc.
• Ensures the privacy and security of PHI (Protected Health Information) as outlined in Fallon policies and procedures related to HIPAA compliance.
• Participates in internal and external QI audits.
• Develop, update, and/or review policies and process documents
• Read and interpret standards/requirements and/or technical specifications
• Develop educational materials for members and/or providers

Education:

Bachelors Degree in nursing preferred.

License/Certifications

• RN with a current Massachusetts nursing license.
• CPHQ certification preferred

Experience

• Minimum of 3-5 years experience in Managed Care setting.
• Quality management/performance improvement, Lean-Six Sigma certification preferred.
• Strong clinical, interpersonal, analytical and communication skills.
• Knowledge in medical record review with proven results.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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