About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Brief summary of purpose:
Summary: This position will contribute to an important strategic initiative of Fallon Health in improving the quality of care of our members. With supervision from the Senior Manager Accreditation, the quality Improvement nurse will be responsible for carrying out the assigned quality improvement initiatives such as the development and implementation of member outreach strategies, and the acquiring of clinical quality data analysis, and presentation to internal and external customers. Other responsibilities include medical record data abstraction and the development of clinical quality initiatives. The nurse will provide clinical expertise and support for departmental initiatives and the Quality Services program structure.
- Work with quality department leadership to develop performance improvement programs that support Fallon’s long-term goals.
- Development and implement innovative member outreach strategies for wellness care and immunizations as well as general health promotion and prevention.
- Assists in the planning, training, implementing, monitoring, analyzing and reporting Quality Improvement activities that are designed to ensure that Fallon members receive quality care in compliance with regulatory and contractual requirements.
- Maintains clinical registries to manage data that supports clinical quality improvement activities.
- Designs and assists with the generation of practitioner and member specific reports of health information for the purpose of improving overall rates of compliance to clinical guidelines and standards of care.
- Provides expertise, documentation and review for all regulatory and accreditation requirements, including but not limited to:NCQA which includes HEDIS, Medicare, MassHealth, and External Quality Review Organizations.
- Reviews and abstracts paper and electronic medical records for various departmental needs and projects and when necessary reviews medical records at medical facilities using standardized criteria adhereing to corporate and departmental policies and procedures.
- Particpates in the development of the annual Quality Work Plan and Work Plan Evaluation.
- Assist in annual development of the Performance Improvement Projects as required.
- Maintains case review data base and provides quarterly reporting.
- Participates in special projects as assigned, such as the GIC clinical performance guarantees, MassHealth quality goals, etc.
- Supports Fallon’s continuous accreditation readiness program to maintain compliance with regulatory standards.
- Ensures the privacy and security of PHI (Protected Health Information) as outlined in Fallon policies and procedures related to HIPAA compliance.
- Participates and facilitates internal and external QI audits.
Bachelor’s Degree in nursing or related field preferred.
RN with a current Massachusetts nursing license.
- Minimum of 3-5 years’ experience in a healthcare setting.
- Quality management/performance improvement experience preferred.
- Working knowledge of adult learning theory and behavior modification strategies.
- Must possess strong interpersonal, analytical and communication skills.
- Competent in medical record review and data abstraction.
- Ability to protect high degree of proprietary business information.
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.