RN Coordinator - Clinical Performance Improvement

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SummaCare - 1200 E Market St, Akron, OH

Full-Time / 40 Hours / Days

*Hybrid after training

As a regional, provider-owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is a part of Summa Health, an integrated healthcare delivery system that includes Summa Health System hospitals, its community-based health centers, dedicated clinicians and SummaCare. Based in Akron, Ohio, SummaCare provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.

Summary :
Enacts and maintains quality improvement activities to meet CMS regulatory guidelines for processing beneficiaries’ quality of care (QOC) grievances. Meets CMS timeliness for completing a QOC review. Prepares and presents findings to Peer Review Committee and Credentialing Committee. Reviews and maintains health plan Clinical Practice Guidelines and maintains New Technology policies in compliance with regulatory guidelines to meet NCQA Health Plan Accreditation. Participates in review and development of member education and preventive health guidelines.

Formal Education Required :
a. Bachelor degree in Nursing or the equivalent in training and experience

Experience & Training Required :
a. Two (2) years performing same or similar responsibilities. Relevant experience includes performing quality or clinical related reviews or project management in either quality management or clinical care areas.

Required Licenses and/or Certificates:
a. Registered Nurse (RN) Ohio license in good standing

Essential Functions & Responsibilities:

1. Review all potential Quality of Care grievances to determine appropriateness.

2. Investigate Quality of Care grievances to identify potential areas of clinical performance improvement.

3. Maintain frequent communication with providers to investigate Quality of Care concerns.

4. Collaborate with health plan Appeals and Grievance department to complete timely investigations.

5. Identify member needs and refer for care coordination outreach.

6. Write member Quality of Care correspondence according to CMS guidelines.

7. Supports Utilization Management and Benefit Determination Unit through development of New Tech polices and Clinical Practice Guidelines.

8. Conducts internal audits in accordance with regulatory and accreditation requirements and ORC Peer Review statutes.

9. Prepares accurate reports in accordance with regulatory and accreditation standards and ORC Peer Review statutes.

10. Contribute to annual Clinical Campaigns to promote member engagement and improve Health Plan HEDIS and 5 Star Rating.

Other Skills, Competencies and Qualifications:
a. Research, understand, analyze, interpret and apply standards and regulations as they apply to HEDIS and CMS.
b. Apply principles of logical thinking to define problems, collect data, establish facts and draw valid conclusions.
c. Work autonomously in a team-based environment.
d. Organize and manage time to accurately complete tasks within designated timeframes in a fast paced environment.
e. Maintain current knowledge of and comply with regulatory and company policies & procedures.
f. Maintain confidentiality of patient and physician information in all respects of review activities.
g. Ability to adjust work hours to meet business demands
h. Ability to travel throughout the workday
i. Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity

Level of Physical Demands:
a. Medium: Exerts 20-50 pounds of force occasionally and/or 10-25 pounds of force frequently, and/or a negligible amount of force continuously to move objects
b. Sit for prolonged periods of time
c. Bend, stoop, and stretch
d. Manual dexterity to operate computer, phone, and standard office machines

Equal Opportunity Employer/Veterans/Disabled

$34.00/hr - $50.99/hr

The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.

Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.