Quality Professionals in Health Insurance Offer Alternative Career Path

Nancy Ross Bell, RN

Nurses working in quality at health insurance companies add high value to the organization and to the members they serve. The number of positions available depends upon the size of the organization and various product offerings. Their responsibilities include data analysis, coordinating quality improvement interventions, overseeing companies providing services, managing accreditation processes, resolving grievances, and supporting committees on quality. One unique qualification desired by most companies are nurses who are certified in healthcare quality. Experienced nurses with a strong passion for high quality healthcare should look closer at these positions.

Value Proposition

Quality professionals bring immense value to organizations. For example, they lead quality initiatives that improve health outcomes; collaborate on strategies to improve member satisfaction; gain efficiencies through process improvements; lower risk by monitoring for regulatory compliance; and coach teams on determining root causes of identified opportunities. Organizations may see results such as with achieving higher rates in HEDIS®, CAHPS®, and Stars measures; members' feedback on eliminating hassle factors; easier access to care; avoidance of penalties due to non-compliance; and more engaged employees on quality teams.

Certified Professional in Healthcare Quality (CPHQ) are known to bring higher levels of competency to organizations, thereby increasing their value. The National Association for Healthcare Quality (NAHQ)® is the leader in the development of healthcare quality competencies and has certified nearly 14,000 nurses globally as CPHQ.¹

Positions in Quality

When searching for positions as a quality professional, look for keywords such as quality improvement, quality management, quality assurance, compliance, HEDIS, CAHPS, Stars, health plan accreditation, or grievances, and titles like analyst, coordinator, lead, or specialist. The number of nurses working in quality at a health insurance company typically depends upon the number of product lines offered including Commercial, Medicare Advantage, Medicaid, or Exchange (ACA), and their products-Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or Point-of-Service (POS). Other factors that impact staffing can include the number of legal entities being accredited, size of provider network(s), and the type of non-nursing support colleagues.

Responsibilities

Quality professionals may be responsible for a specific area of work, for example, managing clinical grievances, while others may work cross-functionally like both accreditation and data analysis. Though organizations vary, the responsibilities of quality professionals are similar.

Analyze data

Quality professionals who specialize in health data analytics analyze HEDIS, CAHPS, and Stars data, combined with data on demographics, claims, and external benchmarks. They collaborate on targeting areas for quality improvement, such as population health management. Quality professionals may also document abstracted data from other IT systems to use for annual HEDIS measurements.

Intervene to drive higher quality

Quality professionals take the lead on projects, for example, how to increase the rate of members among vulnerable populations who receive screening for high blood pressure. They conduct root cause analysis, design innovative ways to engage members, manage change, and integrate best practices across the organization.

Monitor services performed by a delegated entity

Most health insurance companies contract for certain members services such as pharmacy benefit management or chronic condition management. Quality professionals assist in holding external entities accountable for areas of responsibility important to quality management.

Lead organizations on health plan accreditation(s)

Quality professionals assure readiness of the company pursuing the National Committee for Quality Assurance (NCQA)® Health Plan Accreditation, or other related accreditations. They interpret and advise on standards and measures, and develop processes, workflows, materials, and reports for ongoing compliance. Quality professionals are subject matter experts on areas including population health management, utilization management, member experience, quality management and improvement, provider credentialing and/or network management.

Participate in management of quality structure

Because of their organizational skills, attention to detail, and expertise on quality, most quality professionals support various quality committees. They may take charge of a committee, collaborate on clinical reports, communicate project statuses, and/or help with administrative tasks.

Investigate and resolve grievances

In some organizations, grievances related to quality-of-care fall under quality management. Quality professionals may research and respond to member and/or provider grievances, analyze trends, and collaborate with physicians and servicing providers on actions to avoid future adverse events.

Background and Special Characteristics

An ideal background and special characteristics for a nurse working as a quality professional start with having a strong passion for healthcare quality improvement. Others include:

Registered Nurse license/BSN degree/Master's degree preferred
3-5 years clinical experience, preferably with background in quality improvement, accreditation, or data analytics, depending upon the role
A commitment and action towards certification as a CPHQ within two to three years after hire, or when qualifications are met
Proficiency in Microsoft Word, Excel, and PowerPoint products

Personal characteristics

Accountable -Timelines must be met.
Approachable –Accessibility promotes cooperation.
Analytical – Analyzing data crosses all quality functions.
Collaborative – Nurses work with interdisciplinary teams.
Curious – Curiosity leads to innovation and strong interventions.
Critical Thinker- Critical thinking fosters improved decision-making.
Detail-oriented – Attention to detail helps improve accuracy and prevents errors.
Influencer -Nurses work cross-functionally and coach individuals.

Tips

To help prepare nurses seeking a future role in quality, but may need a bit more experience, here are some tips.

Volunteer to participate in or lead a quality improvement committee.
Collect data from the front line for a process improvement initiative.
Interview patients or families about their experiences.
Organize and analyze data.
Conduct a root cause analysis of an identified opportunity.
Shadow a quality professional at your organization or a local health plan.
Practice presenting quality improvement projects to committees and/or leadership.

Conclusion

Working as a quality professional at a health insurance company can be a rewarding career. As nurses consider their future in healthcare, I encourage those with a strong passion for quality to investigate alternative roles.

Nancy Ross Bell, RN, MBA, FACHE, CPHQ

References/Resources

¹About NAHQ

National Association for Healthcare Quality (NAHQ)®

National Committee for Quality Assurance (NCQA)

Centers for Medicare & Medicaid Services (CMS)