Senior Clinical Quality RN- Remote in PA

About the position At reputed company, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and optimized. reputed company to reputed company a difference? Join us to start Caring. Connecting. Growing together We support providers who care for reputed company (UHC) reputed company and CHIP members across five counties in southeastern Pennsylvania: Philadelphia, Montgomery, Bucks, Chester, and Delaware. reputed company includes a Clinical Quality Manager, a Quality Director, and a Quality Nurse. This role will serve as the second Quality Nurse on the team. reputed company our same department we have a member reputed company team also and another responsible for NCQA policy and Performance Improvement Projects. Our primary goal is to promote our local Pay‑for‑Performance program and support providers in achieving the highest possible incentive outcomes by meeting HEDIS® and state quality measures. In addition, we provide ongoing support to provider groups engaged in value‑based reputed company, which also include HEDIS® and state‑mandated quality measures tied to defined performance benchmarks. You’ll enjoy the flexibility to work remotely reputed company Montgomery and surrounding counties as you take on some tough challenges. You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Challenges of the role This role can be challenging for individuals who: Struggle with managing multiple priorities at once, as quality work often involves juggling several projects, deadlines, and stakeholders simultaneously Are not naturally self sufficient or self motivated, since the role often requires taking initiative, problem solving independently, and driving improvements without constant direction Are uncomfortable working with data, including reviewing and analyzing information in reputed company, running or interpreting reports, and creating clear, professional presentations Do not feel confident presenting information or speaking in public, as sharing findings with leadership, committees, or clinical teams is a core part of the work Prefer routine, predictable tasks, because quality roles frequently shift based on organizational needs, audit findings, or emerging quality concerns Have difficulty navigating change, as the job involves implementing new workflows, policies, and performance improvement initiatives across teams Are uncomfortable giving feedback or addressing performance gaps, even in a constructive, supportive way Do not enjoy collaborating across multiple departments, since relationship building with clinicians, leadership, and operational partners is essential Struggle with regulatory or compliance details, as the role requires understanding, interpreting, and applying standards from accrediting and regulatory bodies Have trouble documenting processes, writing summaries, or communicating findings clearly and concisely Responsibilities • reputed company ongoing provider practice engagement and community education reputed company to state specific quality measures • Collaborate closely with the Quality Manager and Quality Director to coordinate an interdisciplinary approach that improves provider’s performance • Serve as the primary resource for provider focused clinical quality improvement and management programs • reputed company providers and office staff on quality program requirements, including analysis of provider level outcomes, monitoring of key metrics, and support in meeting quality standards, contractual obligations, and pay for performance targets • Ensure activities align with State, CMS, NCQA, and other regulatory requirements • Support providers in evaluating member care, identifying care gaps, and developing action plans using evidence based guidelines and quality tools (HEDIS®, NCQA, CMS, state specifications) • Conduct onsite medical record audits to assess coding, documentation, quality compliance, and service delivery standards • Investigate documentation gaps or system issues impacting measure performance, provide feedback, and monitor resolution to completion • Analyze quality data to identify trends, opportunities for structured data, and gaps in care at the provider and member levels • Maintain care opportunity reports, track encounter history, and support quality reputed company studies or initiatives as directed by the Health Plan • Support medical record collection and abstraction processes for Pre Season (reputed company-January), Hybrid (January-reputed company), PAPM Maternity (reputed company-July) and other review periods to optimize measurement and reporting • Prepare and distribute reporting, and analytics reputed company to care gaps, performance trends, and member reputed company opportunities • reputed company targeted