Clinical Risk Management RN (Remote NC)

LOCATION:  Remote – must live in North Carolina or within 40 miles of the NC border.  Must be willing to travel to the Asheville Office if needed.

GENERAL STATEMENT OF JOB

The Clinical Risk Management Registered Nurse (CRM-RN) provides clinical physical health expertise in Quality Management (QM) to support provider oversight and performance improvement activities. As part of Clinical Quality, the CRM-RN engages in day-to-day provider monitoring, clinical reviews, and the management of critical incidents to identify problematic practices and adverse clinical risk trends.

The CRM-RN advises on the incident reporting process, facilitating the communication of trends to leadership teams and internal committees, thereby supporting the oversight of quality, safety, and improvement. Additionally, the CRM-RN collaborates with QM Operations and Quality teams to reduce member harm. Serving as a team member within QM, the CRM-RN aims to mitigate risks and ensure high-quality care within the healthcare environment.

The CRM-RN provides expert consultation on clinical risk management to ensure the highest quality of care in a dynamic healthcare environment. The CRM-RN identifies problematic practices and adverse clinical risk trends, collaborating with the appropriate operations teams to mitigate or eliminate risks to member safety. The CRM-RN diligently works to identify circumstances and opportunities that pose risks to members, taking proactive measures to prevent or control these risks. Additionally, the CRM-RN communicates and collaborates with leadership to develop strategies for risk minimization, identify risk reduction interventions, and promote member safety.

ESSENTIAL JOB FUNCTIONS

Quality Management and Provider Performance Improvement Oversight:

• Provide clinical physical health expertise in Quality Management to support provider oversight and other quality-related activities.
• Offer expertise in monitoring physical health provider records and reviewing providers in relation to DHHS priority quality measures (e.g., opioid misuse, tobacco cessation, pregnancy intendedness, birth outcomes, diabetes prevention, hypertension).
• Assist in the development and implementation of processes and protocols aimed at improving member outcomes.
• Collaborate with leadership to develop tools and programs that support the organization’s goals.
• Efficiently complete Clinical Quality monitoring activities to assess provider quality against best practices and compliance with rules, regulations, and service definitions, while maintaining the integrity of the review process.
• Review and evaluate medical and/or behavioral service outcomes by applying clinical expertise and administrative policy knowledge.
• Maintain current clinical, contract, and policy knowledge, applying it appropriately as part of the monitoring and oversight process.
• Generate Reports of Findings and Results Letters to address review outcomes and identified quality issues.
• Implement monitoring systems to enhance the performance of contracted providers within the Vaya Health Network and improve member outcomes.
• Develop innovative interventions to address and identify treatment gaps within the Vaya Health Network of contracted providers.
• Engage in direct intervention and education with providers regarding healthcare delivery system quality interventions.
• Complete tracking and monitoring systems as required by regulatory requirements, accreditation standards, policies and procedures, protocols, and contractual obligations.
• Serve as a subject matter expert (SME) in physical health and quality improvement for team members and external stakeholders.
• Participate in desk reviews and on-site reviews as needed.
• Assist in the preparation and execution of external regulatory and accreditation reviews as required.
• Collaborate with internal teams and external stakeholders to develop quality solutions when opportunities for improvement are identified.
• Review reports and data to identify trends and patterns impacting service quality and delivery and develop solutions to address non-compliances.

Critical Incident Oversight:

• Serves as the primary clinical Subject Matter Expert (SME) for incidents.
• Utilizes a high degree of judgment, prioritization, problem-solving, and decision-making skills to conduct comprehensive reviews of quality-of-care incidents.
• Provides clinical support for the Critical Incident Review Committee (CIRC) process, including initial clinical triage of incident reports to ensure a consistent flow of incidents and the implementation of immediate performance improvement interventions as needed.
• Leads and directs daily critical incident review prioritization activities.
• Identifies and gathers necessary documents for critical incident review and remediation.
• Collaborates with the Chief Medical Officer (CMO) and/or Deputy CMO as part of the CIRC process and case disposition, as needed or requested.
• Completes provider technical assistance and post-clinical activities following CIRC meetings.
• Offers guidance and consultation on clinical risk management issues, policies, procedures, and practices from a risk management perspective.

Special Projects and Committee Involvement:

• Assist Quality Management (QM) Leadership with special projects and assignments directly related to quality assurance and provider monitoring, and lead such projects as assigned.
• Collaborate with the Quality Management leadership team on departmental projects.
• Represent Vaya Health on internal committees as assigned.
• Participate in external committees and workgroups as assigned.
• Attend NCDHHS Department meetings as needed or assigned to stay informed and maintain a current knowledge base of performance metrics and local, state, and federal requirements.
• Provide ongoing staff development and support as requested to assist the department in fulfilling its responsibilities.
• Collaborate with the Quality Director and Medical Operations to implement Patient Safety principles across the organization and provider network.

KNOWLEDGE, SKILL & ABILITIES

• Demonstrates comprehensive knowledge of rules, regulations, and contractual standards related to behavioral health and medical performance methods and practices, with a focus on improving member outcomes, providing technical assistance, and implementing plans of correction.
• Possesses in-depth understanding of the treatment and service needs of members, with skills in assessing strengths and needs, developing treatment plans, and implementing medical and clinical services.
• Exhibits strong organizational skills and attention to detail, capable of independently managing multiple tasks efficiently. Demonstrates flexibility, adaptability, accountability, and self-governance.
• Utilizes problem-solving, negotiation, and conflict resolution skills to balance the needs of internal and external customers. Effectively negotiates with teams, providers, and other departments to address issues of concern.
• Self-motivated and able to work effectively with a diverse range of individuals, teams, providers, and departments to address issues of concern.
• Maintains a positive, solution-focused attitude and the ability to adapt to changing priorities.
• Possesses highly effective communication skills, capable of presenting information across various audiences and responding to questions from internal and external stakeholders.
• Exhibits excellent decision-making abilities based on relevant facts and established processes to determine appropriate actions during quality reviews and follow-up.
• Demonstrates exceptional interpersonal and leadership skills, able to work both autonomously and as part of a team, exercising sound judgment and problem resolution skills.
• Respects and works effectively with individuals from diverse ethnicities, cultures, and abilities, establishing respectful relationships and partnerships.
• Proficient in Microsoft Office products (e.g., Word, Excel, Outlook).
• Knowledgeable in CPT, ICD, and HCPCS coding.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Associate Degree in Nursing required. Must have:

• at least three years of experience in the field of mental health, intellectual/developmental disabilities, or substance use disorders is required. 
• At least two years of experience in quality management/improvement/assurance
• At least two years of experience in management/supervision

Required Licensure/Certification:

• Current, unrestricted Clinical License as a Registered Nurse
• CLEAR/NCIT - Basic Certified Investigator (should be obtained within the first 9 months of employment)

Preferred Work Experience:

• At least four years of progressive experience in the field of mental health, intellectual/developmental disabilities, or substance use disorders.
• Experience in quality improvement and management/supervision.
• Experience in a hospital or clinical setting within past 3 years
• Two (2) years’ experience with Healthcare/Health Plan.
• Experience completing compliance reviews and preparing written reports
• Experience in quality improvement, analysis, and development in public health or related area.
• Experience with Health Plan Employer Data Information Set data collection (HEDIS) and National Committee for Quality Assurance (NCQA) accreditation activities.
• Experience in a variety of nursing settings including quality improvement, patient satisfaction, and/or outcomes management

Preferred Licensure/Certification:

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. 
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers. 
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. 
• Mental concentration is required in all aspects of work. 

RESIDENCY REQUIREMENT:  The person in this position must reside in North Carolina or within 40 miles of the NC border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. 

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.