Quality Improvement Coordinator /Registered Nurse (RN) for the Health Plan - Remote in Virginia

City/State
Norfolk, VA

Work Shift
Multiple shifts available

Overview:

Sentara Health Plansis hiring a Quality Improvement Coordinator /Registered Nurse (RN) for the Health Plan - Remote in Virginia!

Status: Full-time,permanent position (40 hours)

Standard working hours: 8am to 5pm EST, M-F

Location: This position is remote and applicants must be located in Virginia.

There are a total of 3 open positions under the Quality Improvement Coordinator role for the Health Plan (2 for Critical Incident Investigations and 1 for Special Projects).

Overview for Quality Improvement Coordinator for Special Projects

• The Quality Improvement (QI) Coordinator is responsible for leading and coordinating multi-year Quality Improvement initiatives and strategic projects that support population health, regulatory compliance, and performance improvement in alignment with Virginia Medicaid (DMAS), CMS regulations, and Sentara Health Plans (SHP) Quality Program goals.
  
  This role oversees the planning, execution, monitoring, and evaluation of Special Projects, conducts monthly EPSDT Provider Documentation Medical Record Reviews, and supports data-driven decision-making through analysis, reporting, and performance tracking. The position operates under the direction of the Manager, with oversight from the Director, to ensure successful project outcomes and sustained quality improvement.

Essential Duties and Responsibilities

Quality Improvement Project Leadership

• Leads and manages assigned Special Projects, including multi-year (1-3 year) Quality Improvement initiatives designed to improve population health outcomes and meet regulatory and organizational priorities.
• Develops project plans, timelines, milestones, and deliverables, ensuring alignment with SHP strategic goals.
• Monitors project progress, identifies risks, and implements mitigation strategies to ensure successful completion.
• Collaborates with cross-functional teams to advance project objectives and achieve measurable outcomes.
• Prepares and delivers project updates, summaries, and recommendations to leadership, committees, and workgroups.

DMAS EPSDT Provider Documentation Medical Record Reviews

• Conducts monthly EPSDT Provider Documentation Medical Record Reviews in accordance with DMAS requirements and established review tools.
• Evaluates medical records for compliance with documentation standards, completeness, and quality of care indicators.
• Communicates review findings, trends, and opportunities for improvement to providers and internal stakeholders.
• Supports provider education and corrective action follow-up to improve documentation compliance and quality outcomes.

Quality Improvement Projects (Special Projects)

• Coordinates and executes Quality Improvement Team projects focused on performance improvement, regulatory initiatives, and population health priorities.
• Applies quality improvement methodologies to identify performance gaps, root causes, and opportunities for intervention.
• Supports implementation and evaluation of targeted interventions to drive sustained improvement.

Data Analysis, Reporting, and Performance Monitoring

• Performs data analysis and trending to identify opportunities for improvement across quality initiatives.
• Develops and maintains reports, dashboards, and visualizations to monitor project progress and performance.
• Tracks and monitors key performance indicators (KPIs) tied to Special Projects and regulatory requirements.
• Translates data into actionable insights and recommendations to support decision-making and continuous improvement.

Regulatory Compliance and Documentation

• Ensures compliance with DMAS contract requirements, CMS regulations (including 42 CFR •438), and SHP Quality Program standards.
• Maintains accurate documentation and tracking of project activities, outcomes, and regulatory requirements.
• Prepares reports, data, and supporting documentation for audits, regulatory reviews, and oversight activities.

Performance Improvement and Continuous Quality Improvement

• Supports continuous quality improvement efforts through data-driven analysis, performance monitoring, and intervention design.
• Assists with development and monitoring of corrective action plans (CAPs) to ensure sustained improvement.
• Promotes a culture of quality, accountability, and regulatory readiness across initiatives.

Quality Improvement Tools and Systems

• Develops and maintains Quality Improvement tracking tools, including Excel-based trackers and project management resources.
• Utilizes reporting platforms and data systems to track, analyze, and report on quality initiatives.
• Ensures accuracy and integrity of data used for reporting and performance monitoring.

Collaboration and Communication

• Collaborates with internal departments including Care Management, Care Coordination, Value-Based Care, Network Management, Compliance, and other stakeholders.
• Engages with providers and external partners to support EPSDT reviews and quality initiatives.
• Provides education and guidance related to quality improvement, documentation requirements, and regulatory expectations.

Core Competencies

• Project management and organizational skills
• Data analysis and performance monitoring
• Critical thinking and root cause analysis
• Strong written and verbal communication
• Collaboration and stakeholder engagement
• Attention to detail and regulatory compliance

Overview for Quality Improvement Coordinator for Critical Incident Investigations

The Quality Improvement (QI) Coordinator is responsible for coordinating and conducting Quality Improvement activities related to Critical Incident investigations, Quality of Care (QOC) and Quality of Service (QOS) reviews, and member safety oversight in accordance with Virginia Medicaid (DMAS) requirements, CMS regulations, and Sentara Health Plans (SHP) policies and procedures.

This role supports the Quality Improvement Program by ensuring timely identification, investigation, documentation, analysis, and resolution of Critical Incidents and quality concerns, while promoting continuous quality improvement and optimal care outcomes for SHP members.

Essential Duties and Responsibilities

Critical Incident Management

• Receives, reviews, and coordinates Critical Incident reports, including but not limited to abuse, neglect, exploitation, sentinel events, mortality reviews, and serious quality of care concerns, in accordance with DMAS and CMS requirements.
• Ensures timely reporting, investigation, follow-up, and closure of Critical Incidents within required regulatory timeframes.
• Conducts comprehensive reviews of medicais records, incident reports, and supporting documentation to assess appropriateness of care, services rendered, and member safety outcomes.
• Identifies trends, root causes, and systemic issues contributing to Critical Incidents and communicates findings to leadership.

Quality of Care and Quality of Service Reviews

• Coordinates and performs Quality of Care (QOC) and Quality of Service (QOS) investigations, including grievances and referrals from internal and external stakeholders.
• Applies established clinical and quality standards to determine quality determinations and facilitate corrective actions per the Medical Directors' recommendations, when indicated.
• Drafts clear, concise investigative summaries, determinations, and correspondence for internal review, regulatory reporting, and provider communication.

Regulatory Compliance and Documentation

• Ensures compliance with DMAS contract requirements, CMS regulations (including 42 CFR •438), and SHP Quality Program policies.
• Maintains accurate documentation and case tracking in designated systems (e.g., quality tracking tools, databases, and reports).
• Prepares data, reports, and supporting documentation for regulatory audits, reviews, and oversight activities, including DMAS, CMS, and external quality review organizations.

Performance Improvement and Reporting

• Supports Quality Improvement initiatives by contributing to performance monitoring, trend analysis, and targeted improvement activities related to member safety and quality outcomes.
• Assists with the development and monitoring of Corrective Action Plans (CAPs) and follow-up activities to ensure sustained improvement.
• Participates in Quality Committees, workgroups, and interdisciplinary meetings as assigned.

Collaboration and Communication

• Collaborates with internal departments including Care Management, Medical Directors, Behavioral Health, Compliance, and Provider Relations.
• Coordinates with external stakeholders such as providers, facilities, and community agencies as needed to support investigations and quality improvement efforts.
• Provides education and guidance to staff and providers related to Critical Incident reporting requirements and quality expectations.

Core Competencies

• Attention to detail and regulatory accuracy
• Written and verbal communication
• Critical thinking and root cause analysis
• Time management and prioritization
• Collaboration and professionalism
. click apply for full job details