Utilization and Quality Nurse

Description

PRIMARY PURPOSE:

To support utilization management, quality improvement, population health, and performance improvement activities within FoundCare, promoting high-quality, patient-centered, cost-effective care while ensuring compliance with HRSA, UDS, CMS, value-based care, and payer requirements. This position works collaboratively with providers, care teams, leadership, and community partners to identify care gaps, improve clinical outcomes, optimize resource utilization, and support quality initiatives focused on preventive care and chronic disease management.

ESSENTIAL JOB FUNCTIONS:

Promote the mission, vision, and values of FoundCare.

1. Quality Improvement

• •Coordinate and participate in the organization’s Quality Improvement (QI) and Performance Improvement (PI) programs.
• •Monitor and analyze quality metrics, including UDS, HEDIS, CMS quality measures, and value-based care indicators.
• •Conduct chart audits to evaluate compliance with clinical guidelines, documentation standards, and regulatory requirements.
• •Develop and implement quality improvement initiatives and corrective action plans.
• •Track provider performance and identify opportunities to improve quality outcomes.
• •Prepare quality reports and dashboards for leadership, the Quality Committee, and Board meetings.
• •Participate in root cause analyses and performance improvement activities.
• •Assist with accreditation, credentialing, and regulatory readiness activities.

2. Utilization Management

• •Review utilization data to identify trends in referrals, diagnostic testing, emergency department utilization, hospital admissions, and readmissions.
• •Collaborate with providers and care teams to promote appropriate utilization of health care services.
• •Monitor specialty referrals and follow-up outcomes.
• •Support care coordination and transitions of care for high-risk patients.
• •Participate in denial management and identify opportunities to improve payer compliance and reimbursement.

3. Population Health Management

• •Utilize EHR reports and population health tools to identify patients with care gaps and unmet health needs.
• •Support programs aimed at improving outcomes for patients with diabetes, hypertension, HIV, Hepatitis C, asthma, cardiovascular disease, and other chronic conditions.
• •Assist with patient registries and risk stratification initiatives.
• •Monitor quality measures and implement interventions to improve compliance rates.

4. Regulatory Compliance

• •Ensure compliance with HRSA Health Center Program requirements, UDS reporting standards, CMS regulations, payer requirements, and organizational policies.
• •Maintain accurate and timely documentation of quality and utilization activities.
• •Participate in internal and external audits.
• •Support implementation of evidence-based clinical practice guidelines.

5. Education and Collaboration

• •Educate clinical staff on quality initiatives, documentation requirements, clinical measures, and best practices.
• •Provide feedback to providers regarding quality performance and opportunities for improvement.
• •Participate in multidisciplinary meetings and quality committees.
• •Collaborate with leadership to develop strategies that improve patient outcomes and operational efficiency.
• •Perform other duties as assigned.

Requirements

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

• •Knowledge of FQHC operations and HRSA compliance requirements.
• •Understanding of health care quality metrics and performance improvement methodologies.
• •Familiarity with UDS, HEDIS, CMS Quality Measures, and value-based reimbursement models.
• •Knowledge of utilization review and population health principles.
• •Strong analytical, organizational, and problem-solving skills.
• •Ability to interpret clinical data and generate meaningful reports.
• •Ability to work independently and collaboratively within multidisciplinary teams.
• •Proficiency in Microsoft Office Suite, including Outlook, Word, and Excel, and the ability to navigate electronic health record systems.
• •Ability to communicate effectively in the English language, orally, in writing, and electronically.
• •Ability to review, understand, and apply concepts presented in training programs, conferences, and/or professional literature.
• •Ability to maintain confidentiality of all patient and organizational information in accordance with HIPAA regulations.
• •Ability to interact and work with diverse populations.
• •Ability to handle difficult situations involving patients, providers, or others, professionally.
• •Clear understanding that FoundCare provides information on educating individuals on safer sex practices which would include but not be limited to, exposure to explicit language, explicit printed material, and descriptions of explicit sexual activities as part of the agency’s mission in the prevention and transmission of HIV disease.

PHYSICAL REQUIREMENTS

• •Ability to endure prolonged periods of sitting, standing, and computer use in performance of job duties.
• •Ability to communicate effectively in person, by telephone, and electronically.
• •Use standard office equipment and technology, including computers, telephones, and clinical equipment and systems, in the course of daily duties.
• •Ability to lift and carry objects weighing 25 pounds or less.
• •Ability to travel to other FoundCare locations and perform job duties.
• •Ability to travel to other locations to attend meetings, workshops, and seminars, plus travel to other FoundCare departments and FoundCare conference rooms.

MINIMUM QUALIFICATIONS:

• •Associate Degree in Nursing required ; Bachelor of Science in Nursing (BSN) preferred .
• •Current and unrestricted Registered Nurse (RN) license in the State of Florida.
• •Minimum of three (3) years of clinical nursing experience.
• •Experience in Quality Improvement, Utilization Management, Case Management, Population Health, Ambulatory Care, Managed Care, or FQHC settings preferred.
• •Experience with UDS reporting, HEDIS measures, and value-based care programs strongly preferred .
• •Certified Professional in Healthcare Quality (CPHQ) or Certified Case Manager (CCM) preferred .
• •This role is not eligible for visa sponsorship.