Clinical Quality Specialist

The Role

This is a clinical leadership position at VNS Health based in New York, NY. You'll lead interdepartmental Quality Improvement (QI) initiatives focused on making sure member care is high quality, safe, and equitable. It's a role where you serve as a clinical and operational resource to QI committees, workgroups, and leadership.

You'll analyze outcomes, HEDIS/CAHPS/Stars performance, and trend data. The goal is to spot opportunities for improvement in care coordination, quality, and member experience. You'll design, implement, and evaluate QI programs that align with DOH, CMS, and NCQA standards. And you'll work across departments ; Care Management, Utilization Management, Provider Relations, Compliance, and Analytics ; to sustain continuous improvement, advance health equity, and ensure regulatory readiness.

What You'll Actually Do

• Conduct clinical assessments including medication reconciliations, post discharge transitions of care assessments, and follow up after emergency department visits.
• Collaborate across departments to ensure compliance with DOH, CMS, and NCQA requirements.
• Coach teams in applying continuous improvement methodologies like PDSA, LEAN, and RCA to hit strategic objectives and national benchmarks for quality, satisfaction, and cost.
• Partner with analytics and program teams to identify trends and address performance gaps.
• Perform clinical reviews with network providers to validate diagnoses, address care gaps, and support accurate HEDIS/QARR documentation.
• Collaborate with providers to improve adherence to evidence based care and quality measures.
• Lead and participate in multidisciplinary QI teams and committees to design, implement, and evaluate improvement initiatives around clinical performance, documentation, and regulatory compliance.
• Support the development of the annual QI work plan, program evaluation, and performance reporting.
• Support value based programs through data review, gap identification, and provider feedback.
• Perform medical record audits to check adherence to documentation, coding, and quality standards.
• Provide education, feedback, and guidance to PCPs on VNS Health Medical Record Documentation Standards.
• Conduct audits of patient care records to monitor care quality and documentation accuracy.
• Develop forms, record abstracts, reports, and other tools for concurrent and retrospective patient care review ; including the design, testing, and evaluation of the review methodology.
• Perform utilization and quality assessment reviews to maintain compliance with Federal and State regulatory requirements.
• Identify and analyze results to inform the development of correction plans.
• Collaborate with management to develop measurable action plans based on root cause analysis, outcome trends, and survey results (HEDIS, CAHPS, Stars).
• Present recommendations to QI committees and leadership to drive improvement and accountability.
• Participate in preparing for and assisting with site visits of external providers for regulatory quality compliance.
• Develop and disseminate training materials, clinical guidelines, and quality protocols to promote consistent evidence based care across provider networks and internal teams.
• Provide education sessions and quality coaching as needed.
• Conduct follow up reviews and reassessments to ensure corrective actions for regulatory findings, complaints, or incidents are implemented effectively and sustained over time.
• Document progress and escalate unresolved issues as appropriate.
• Develop, maintain, and update QI policies and procedures aligned with evolving regulatory and industry standards.
• Collaborate with analytics to collect, interpret, and share performance data with internal teams to drive transparency and accountability.
• Participate in special projects and perform other duties as assigned.

What You Need

• License and current registration to practice as a Registered Professional Nurse in New York State or New Jersey.
• A Bachelor's Degree in Nursing.
• Minimum of three years experience in a health plan or healthcare setting.
• Minimum of three years quality improvement experience is preferred.
• Minimum of one year experience in quality management, practice improvement, and compliance is preferred.
• Demonstrated experience leading or facilitating cross functional quality initiatives is preferred.
• Excellent oral, written, and interpersonal communication skills.

What You Get

• Referral bonus opportunities.
• Generous paid time off starting at 30 days of paid time off plus 9 company holidays.
• A health insurance plan covering Medical, Dental, and Vision for you and your loved ones.
• Life and Disability insurance.
• Employer matched retirement saving funds.
• Personal and financial wellness programs.
• Pre tax flexible spending accounts (FSAs) for both healthcare and dependent care.
• Generous tuition reimbursement for qualifying degrees.
• Opportunities for professional growth and career advancement.
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities.