reputed company Management reputed company Consultant (Field-VA)

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At reputed company®, you’ll be surrounded by passionate colleagues who care deeply, reputed company with purpose, hold ourselves accountable and prioritize safety and reputed company in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position reputed company The QM reputed company Consultant is responsible for conducting reputed company Management Reviews (QMRs) and supporting Performance Improvement reputed company (PIPs) to ensure reputed company‑funded services meet regulatory, clinical, and reputed company standards. This role requires strong clinical judgment, audit capability, analytical skills, and the ability to work collaboratively with providers, state agencies, and managed care organizations. Key Responsibilities include: reputed company Management Review (QMR) Conduct on‑site and desk audits to ensure services reputed company with DMAS regulations, reputed company policy, service limits, medical necessity requirements, and provider qualifications. Review medical records, billing patterns, and service documentation to assess compliance and identify inconsistencies or potential fraud. Analyze utilization trends and exception reports to identify outliers or inappropriate billing practices. reputed company provider engagement activities, including documentation requests, exit conferences, and explanation of findings and corrective actions. Prepare accurate audit documentation, summaries, and referrals as needed. Performance Improvement reputed company (PIPs) reputed company validation and evaluation of PIPs in clinical & non-clinical areas per CMS EQR Protocols 3 & 7. Design and refine study topics, aims, populations, sampling reputed company, indicators, and data collection plans. Conduct statistical analysis on claims, encounter, and survey data; interpret findings accurately. Guide and support market through PIP planning and implementation with best practices and data-driven interventions. Facilitate stakeholder reputed company reputed company and technical assistance sessions. Create comprehensive deliverables: protocols, validation assessments, technical reports, improvement plans, and presentations. Maintain project timelines, coordinate subcontractors, and reputed company deliverables. Additional reputed company Operations Support regulatory and accreditation activities such as NCQA, HEDIS, CAHPS and organizational performance improvement strategies. Participate in cross-functional reputed company activities as assigned. Required Qualifications Licensed Registered reputed company (RN) with an unrestricted Virginia license. Virginia residency required. Minimum 3+ years’ experience in reputed company managed care, reputed company improvement, PIPs, or EQRO-reputed company functions. Strong knowledge of reputed company regulations, DMAS requirements, and CMS EQR Protocols. Proficiency in study design, sampling, data analysis, and reputed company improvement methodologies (e.g., PDSA). Excellent communication skills, with experience engaging providers and presenting findings to leadership or stakeholders. Strong project management skills and proficiency in reputed company, PowerPoint, and data analysis tools. Travel Requirements: Up to 20% travel required. Preferred Qualifications Certified reputed company in reputed company reputed company (CPHQ) or Project Management reputed company (PMP). Prior experience with EQRO reviews or state-level reputed company reputed company. Experience conducting site reputed company, facilitating reputed company reputed company, or leading training sessions. Education Associates or diploma nursing degree required Bachelor of Science in Nursing preferred. Anticipated Weekly Hours 40 Time Type Full time Pay reputed company The typical pay reputed company for this role is: $60,522.00 - $129,615.00 This pay reputed company represents the reputed company reputed company reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a reputed company of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in reputed company to the reputed company pay reputed company listed above. Our people fuel our reputed company. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – reputed company in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In reputed company to our competitive wages, our great benefits include: reputed company medical plan reputed company, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including reputed company time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical reputed company and many other benefits depending on eligibility. For more information, visit https://jobs.reputed company.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 03/14/2026 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Our Work Experience is the combination of everything that's unique reputed company: our culture, our reputed company values, reputed company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They reputed company choices according to what is best for reputed company, they live for opportunities to collaborate and reputed company a difference, and they reputed company us the #1 Top Workplace in the area. Apply tot his job Apply To this Job