The Nurse Manager -- Quality Program is a clinical resource to the Quality Department that also provides administrative management of the meetings and documents of the Quality Program. The role is lead manager of the Quality Management Committee and the two Medical Advisory Committee meetings, and also serves as a clinical resource to the Grievance and Appeals Team, Disease Management, Wellness, and HEDIS gap closure efforts.
Clinical Resource to Grievance and Appeals Managers:
Reviews clinical aspects of cases to provide guidance on whether appeal requests meet accepted evidence-based criteria
Works with internal and external clinical resources – nurse care managers, medical directors – to ensure that appeals cases are properly prepared and contain complete, relevant information.
Acts as a clinical resource to review and present quality of care grievances.
Supports and reviews Senior Whole Health policies and workflows describing the grievance and appeals processes.
Administrative Management of Quality Program Meetings and Documents:
Works with director to plan QMC meeting. Manages production of materials for and takes minutes at Quality meetings (ex. Quality Management Committee, Medical Advisory Committee)
Maintains all meeting documents – agendas, presentations, minutes – in an electronic file structure.
Organizes, prepares for, and takes minutes for monthly Medical Advisory Committee meeting, which occurs after hours and must be attended in person.
Supports development and updating of the key quality documents: The Quality Program Description, The Quality Program Evaluation, the Quality Program Work Plan and the CMS Models of Care.
Supports organization of documents needed to support CMS, state, and NCQA oversight.
Responsible for other duties as they arise.
Clinical Resource to Quality Program for Disease Management, Wellness and HEDIS gaps
Acts as a clinical resource to the Disease Management Program Manager, including supporting the clinical aspects of program development, and participating on the Disease Management Quality Teams.
Acts as a Liaison to the Nurse Care Managers to facilitate inclusion of Disease Management topics in the Care Plan and to train and support coaching strategies for the nurse-member interactions.
Acts as a clinical resource to the Wellness Coordinator, including supporting the clinical aspects of the program development.
Participates in and documents direct member interactions related to gap closure efforts for certain priority measures, including osteoporosis treatment and rheumatoid arthritis treatment.
Specific training and experience related to chronic disease management, particularly diabetes and coronary artery disease, and health and wellness.
Experience working at a health plan -- Medicare and / or Medicaid experience preferred
Seniors hate living in nursing homes; states hate paying for them. Enter Senior Whole Health (SWH), a health services plan that aims to keep more low-income seniors living independently at home. SWH consolidates the benefits of Medicare and Medicaid into one easy-to-join plan that pays claims, handles customer service issues, and contracts with primary care providers. It also offers around-the-clo...ck access to nurses, exercise programs, prescription drug coverage, transportation, and multilingual translators. SWH serves more than 17,000 members in the states of Massachusetts, and New York.