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Quality Improvement Coordinator /Registered Nurse (RN) for the Health Plan - Remote in Virginia

Sentara Health -
Richmond, VA

Quick Apply

Job Details

Full-time
3 days ago

Benefits

403(b) matching
Paid parental leave
Caregiver leave
Disability insurance
Health insurance
Dental insurance
Tuition reimbursement
Paid time off
Parental leave
Employee assistance program
Vision insurance
401(k) matching
403(b)
Life insurance
Pet insurance

Qualifications

Stakeholder relationship building

Full Job Description

City/State

Norfolk, VA

Work Shift

Multiple shifts available

Overview:

Sentara Health Plans is hiring a Quality Improvement Coordinator /Registered Nurse (RN) for the Health Plan - Remote in Virginia!

Status: Full-time, permanent position (40 hours)

Standard working hours: 8am to 5pm EST, M-F

Location: This position is remote and applicants must be located in Virginia.

There are a total of 3 open positions under the Quality Improvement Coordinator role for the Health Plan (2 for Critical Incident Investigations and 2 for Special Projects).

Overview for Quality Improvement Coordinator for Special Projects

The Quality Improvement (QI) Coordinator is responsible for leading and coordinating multi-year Quality Improvement initiatives and strategic projects that support population health, regulatory compliance, and performance improvement in alignment with Virginia Medicaid (DMAS), CMS regulations, and Sentara Health Plans (SHP) Quality Program goals.
This role oversees the planning, execution, monitoring, and evaluation of Special Projects, conducts monthly EPSDT Provider Documentation Medical Record Reviews, and supports data-driven decision-making through analysis, reporting, and performance tracking. The position operates under the direction of the Manager, with oversight from the Director, to ensure successful project outcomes and sustained quality improvement.

Essential Duties and Responsibilities

Quality Improvement Project Leadership

Leads and manages assigned Special Projects, including multi-year (1–3 year) Quality Improvement initiatives designed to improve population health outcomes and meet regulatory and organizational priorities.
Develops project plans, timelines, milestones, and deliverables, ensuring alignment with SHP strategic goals.
Monitors project progress, identifies risks, and implements mitigation strategies to ensure successful completion.
Collaborates with cross-functional teams to advance project objectives and achieve measurable outcomes.
Prepares and delivers project updates, summaries, and recommendations to leadership, committees, and workgroups.

DMAS EPSDT Provider Documentation Medical Record Reviews

Conducts monthly EPSDT Provider Documentation Medical Record Reviews in accordance with DMAS requirements and established review tools.
Evaluates medical records for compliance with documentation standards, completeness, and quality of care indicators.
Communicates review findings, trends, and opportunities for improvement to providers and internal stakeholders.
Supports provider education and corrective action follow-up to improve documentation compliance and quality outcomes.

Quality Improvement Projects (Special Projects)

Coordinates and executes Quality Improvement Team projects focused on performance improvement, regulatory initiatives, and population health priorities.
Applies quality improvement methodologies to identify performance gaps, root causes, and opportunities for intervention.
Supports implementation and evaluation of targeted interventions to drive sustained improvement.

Data Analysis, Reporting, and Performance Monitoring

Performs data analysis and trending to identify opportunities for improvement across quality initiatives.
Develops and maintains reports, dashboards, and visualizations to monitor project progress and performance.
Tracks and monitors key performance indicators (KPIs) tied to Special Projects and regulatory requirements.
Translates data into actionable insights and recommendations to support decision-making and continuous improvement.

Regulatory Compliance and Documentation

Ensures compliance with DMAS contract requirements, CMS regulations (including 42 CFR §438), and SHP Quality Program standards.
Maintains accurate documentation and tracking of project activities, outcomes, and regulatory requirements.
Prepares reports, data, and supporting documentation for audits, regulatory reviews, and oversight activities.

Performance Improvement and Continuous Quality Improvement

Supports continuous quality improvement efforts through data-driven analysis, performance monitoring, and intervention design.
Assists with development and monitoring of corrective action plans (CAPs) to ensure sustained improvement.
Promotes a culture of quality, accountability, and regulatory readiness across initiatives.

Quality Improvement Tools and Systems

Develops and maintains Quality Improvement tracking tools, including Excel-based trackers and project management resources.
Utilizes reporting platforms and data systems to track, analyze, and report on quality initiatives.
Ensures accuracy and integrity of data used for reporting and performance monitoring.

Collaboration and Communication

Collaborates with internal departments including Care Management, Care Coordination, Value-Based Care, Network Management, Compliance, and other stakeholders.
Engages with providers and external partners to support EPSDT reviews and quality initiatives.
Provides education and guidance related to quality improvement, documentation requirements, and regulatory expectations.

Core Competencies

Project management and organizational skills
Data analysis and performance monitoring
Critical thinking and root cause analysis
Strong written and verbal communication
Collaboration and stakeholder engagement
Attention to detail and regulatory compliance

Overview for Quality Improvement Coordinator for Critical Incident Investigations

The Quality Improvement (QI) Coordinator is responsible for coordinating and conducting Quality Improvement activities related to Critical Incident investigations, Quality of Care (QOC) and Quality of Service (QOS) reviews, and member safety oversight in accordance with Virginia Medicaid (DMAS) requirements, CMS regulations, and Sentara Health Plans (SHP) policies and procedures.

This role supports the Quality Improvement Program by ensuring timely identification, investigation, documentation, analysis, and resolution of Critical Incidents and quality concerns, while promoting continuous quality improvement and optimal care outcomes for SHP members.

Essential Duties and Responsibilities

Critical Incident Management

Receives, reviews, and coordinates Critical Incident reports, including but not limited to abuse, neglect, exploitation, sentinel events, mortality reviews, and serious quality of care concerns, in accordance with DMAS and CMS requirements.
Ensures timely reporting, investigation, follow-up, and closure of Critical Incidents within required regulatory timeframes.
Conducts comprehensive reviews of medicais records, incident reports, and supporting documentation to assess appropriateness of care, services rendered, and member safety outcomes.
Identifies trends, root causes, and systemic issues contributing to Critical Incidents and communicates findings to leadership.

Quality of Care and Quality of Service Reviews

Coordinates and performs Quality of Care (QOC) and Quality of Service (QOS) investigations, including grievances and referrals from internal and external stakeholders.
Applies established clinical and quality standards to determine quality determinations and facilitate corrective actions per the Medical Directors’ recommendations, when indicated.
Drafts clear, concise investigative summaries, determinations, and correspondence for internal review, regulatory reporting, and provider communication.

Regulatory Compliance and Documentation

Ensures compliance with DMAS contract requirements, CMS regulations (including 42 CFR §438), and SHP Quality Program policies.
Maintains accurate documentation and case tracking in designated systems (e.g., quality tracking tools, databases, and reports).
Prepares data, reports, and supporting documentation for regulatory audits, reviews, and oversight activities, including DMAS, CMS, and external quality review organizations.

Performance Improvement and Reporting

Supports Quality Improvement initiatives by contributing to performance monitoring, trend analysis, and targeted improvement activities related to member safety and quality outcomes.
Assists with the development and monitoring of Corrective Action Plans (CAPs) and follow-up activities to ensure sustained improvement.
Participates in Quality Committees, workgroups, and interdisciplinary meetings as assigned.

Collaboration and Communication

Collaborates with internal departments including Care Management, Medical Directors, Behavioral Health, Compliance, and Provider Relations.
Coordinates with external stakeholders such as providers, facilities, and community agencies as needed to support investigations and quality improvement efforts.
Provides education and guidance to staff and providers related to Critical Incident reporting requirements and quality expectations.

Core Competencies

Attention to detail and regulatory accuracy
Written and verbal communication
Critical thinking and root cause analysis
Time management and prioritization
Collaboration and professionalism

Education

Bachelor's Degree in Nursing (BSN) preferred
Associate’s Degree REQUIRED or
LPN Diploma may be accepted in lieu of associate’s degree

Certification/Licensure:

Registered Nurse (RN) License (Compact or Virginia) preferred

Experience

3 years of quality improvement experience REQUIRED
3 years of regulatory and accreditation REQUIRED
Nursing background in different settings (acute, ambulatory, home health, hospice, behavioral health) preferred
Health Plan experience preferred

Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees.

Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals.

We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health.

Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.

Benefits

Caring For Your Family and Your Career

Medical, Dental, Vision plans
Adoption, Fertility and Surrogacy Reimbursement up to $10,000
Paid Time Off and Sick Leave
Paid Parental & Family Caregiver Leave
Emergency Backup Care
Long-Term, Short-Term Disability, and Critical Illness plans
Life Insurance
401k/403B with Employer Match
Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
Student Debt Pay Down – $10,000
Reimbursement for certifications and free access to complete CEUs and professional development
Pet Insurance
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met

Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-100944

Talroo-Health Plan

Quality Improvement Coordinator, Registered Nurse, RN, Nursing, Remote, Health Plan, Healthcare, MCO, Managed Care, Health Insurance, Quality Improvement, Regulation, Accreditation, DMAS, CMS, EPSDT, NCQA, HEDIS, Performance Improvement, Data Analytics, Special Projects, Critical Incident Investigations

Benefits: Caring For Your Family and Your Career

Medical, Dental, Vision plans
Adoption, Fertility and Surrogacy Reimbursement up to $10,000
Paid Time Off and Sick Leave
Paid Parental & Family Caregiver Leave
Emergency Backup Care
Long-Term, Short-Term Disability, and Critical Illness plans
Life Insurance
401k/403B with Employer Match
Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
Student Debt Pay Down – $10,000
Reimbursement for certifications and free access to complete CEUs and professional development
Pet Insurance
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission “to improve health every day,” this is a tobacco-free environment.

For positions that are available as remote work, Sentara Health employs associates in the following states:

Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

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