Revenue Cycle Claims Specialist
Finni Health (YC W23)
Nurse Manager, Clinical Integrity and Quality
House + Home Loans
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Conduct regular and targeted chart audits to ensure adherence to clinical guidelines, documentation standards, and payer requirements
- Lead clinical quality control programs aligned with The Joint Commission, HRSA, PCMH, and internal standards
- Evaluate care delivery against HEDIS and UDS measures, including immunizations, screenings, and chronic disease management
- Assist in preparing and coordinating external site visits and accreditation surveys
- Identify documentation gaps or patterns of concern and provide recommendations
- Maintain up-to-date knowledge of HRSA, Medicaid Managed Care, and other regulatory quality expectations
- Review and assess clinical documentation, care delivery processes, and interdisciplinary workflows for accuracy and integrity
- Maintain accurate records of quality reviews, audits, and corrective actions
- Monitor clinical data and patient outcomes to identify high-risk areas and trends
- Work with site leadership to develop, implement, and monitor corrective action plans
- Collect and analyze data to report identified trends, areas for improvement, and potential risks
- Assist in investigation of patient complaints, incidents, and adverse events; conduct root cause analysis and implement corrective actions
- Assist implementation of care initiatives aligned with value-based payment models (TCM, CCM, PCMH) and optimize workflows for payer incentive programs
- Develop and implement quality dashboards, indicators, and scorecards
- Deliver audit feedback and education to providers, nurses, and medical assistants to improve documentation and clinical care
- Develop training materials and conduct sessions on compliance, HEDIS/UDS reporting standards, and integrity
- Collaborate with QI teams, clinical directors, care coordinators, and health IT to ensure seamless quality data collection and use
- Serve as the nursing liaison in interdisciplinary quality teams and provide clinical oversight for performance improvement
- Support creation and implementation of quality control guidelines, policies, and procedures
- Analyze data and compile reports on quality indicators, trends, and performance metrics for committees and leadership
Requirements
- 5+ years of nursing and clinical leadership required
- Active RN License in the State of Texas
- Certified Professional in Healthcare Quality (CPHQ) required or must be obtained with 18 months of holding the position, or equivalent
- Expert knowledge of clinical quality standards, nursing protocols, and healthcare regulatory frameworks
- Skilled in data analysis, audit tools, and performance reporting
- Strong project management, facilitation, and communication skills
- Proficient in EHR systems, quality software, and documentation review tools
- Ability to influence and collaborate across clinical and administrative teams
