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Clinical Quality Improvement Nurse

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POST DATE 9/15/2016
END DATE 11/10/2016

BMC HealthNet Plan Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Designs and develops analyses and reports of a complex and critical nature using healthcare performance measurement software and other modalities regarding the Plan s clinical quality improvement activities including Health Plan Employer Data and Information Set (HEDIS), Clinical Topic Review (CTR), and health improvement studies. Uses clinical knowledge in conducting medical record audits at provider sites.

Key Functions/Responsibilities:

* Performs initial QA and preps annual HEDIS project application

* Organizes, validates and monitors the collection of HEDIS and CTR demographic utilization data with providers. Audits patient medical records for clinical quality performance measures for the Plan s most challenging group practices. (e.g. HEDIS validation studies.)

* Develops communications on healthcare data to affected staff, departments, committees, providers and external agencies.

* Conducts state-of-the-industry research on QI benchmarks/best practices/practice guidelines to identify performance improvement opportunities.

* Designs, prepares and presents reports, analysis, and educational reference materials to internal and external constituents. Leads the internal operation of key departmental quality improvement activities.

* Reviews and recommends strategies to improve HEDIS scores and develops tracking and progress reports for clinical performance measurements.

* Provides education, consultation, corrective action and follow up with provider sites on process improvement and quality improvement opportunities.

* Designs and develops data collection tools, data analysis and data presentation. Provides decision support and testing to development of applications that support departmental requirements. Monitors the results of improvement efforts and advises on further interventions.

* Provides critical feedback to HEDIS chart review vendor for process improvement

* Supports cross-departmental Plan policies by fulfilling chart and supplementary data requests

* Prepares for external chart audits

* Designs and conducts research studies to improve knowledge of plan HEDIS rates

* Collaborates with Clinical Quality Manager to provide training and technical assistance to Clinical Quality Improvement Coordinators.

* Reviews medical records for members identified with target conditions for complete and accurate coding

* Regular and reliable attendance is an essential function of the position.

Supervision Exercised:

* May provide technical support to Clinical Quality Improvement Coordinators.

Supervision Received:

* Indirect supervision is received weekly.



* Bachelor's Degree in Nursing, Healthcare Administration, Quality, related field, or an equivalent combination of education, training and experience is required.


* 4 or more years experience in clinical research and/or quality improvement activities in a health or managed care environment required.

* Comprehensive knowledge of clinical research, quality improvement activities, or HEDIS performance measures required.

Certification or Conditions of Employment:

* Pre-employment background check

Competencies, Skills, and Attributes:

* Ability to analyze, compile, format and present data to a variety of groups and individuals.

* Understanding of medical record review process and clinical and quality terminology.

* Comprehensive knowledge of statistical processes.

* Demonstrated ability to develop collaborative relationships with all levels of medical staff and Plan staff and to lead and facilitate group process.

* Demonstrated ability for independent problem solving.

* Expertise utilizing Microsoft Office products especially Excel, ACCESS or similar database and report writer.

* Ability to master multiple proprietary electronic applications

* Effective communication skills (verbal and written).

Working Conditions and Physical Effort:

* Ability to work OT during peak periods.


Boston Medical Center Health Plan, Inc. (BMCHP) is a not-for-profit health maintenance organization founded in 1997 by Boston Medical Center. BMCHP’s Massachusetts business, BMC HealthNet Plan, serves over 260,000 members across the state and offers coverage to New Hampshire’s 115,000 Medicaid managed care program recipients. In New Hampshire, the organization operates under the name Well Sense Health Plan.Healthcare is one of the most dynamic and rapidly growing industries in the U.S. Working at our organization will challenge your knowledge and skills, while providing you with opportunities to participate in training and development programs that will help you achieve your professional goals. Whether it’s your first job or you want to take the next step in your career, we offer many rewarding positions in a welcoming, diverse work environment. Learn more about available job openings today.

Company Size:
501-1,000 Employees
Health Care
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2 Copley Place Suite 600
Boston, MA 02116

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