Quality Assurance Specialist - RN

Focus Care is a healthcare organization dedicated to serving Medicare and Medicaid patients. At Focus Care we understand providers and plans mission to deliver exceptional quality care for their members, while maximizing their efficiency and revenue. That is why there is only ONE health care services company that maintains a continuum of care coordination, health needs assessments and clinical consulting all in one place. As a total solutions partner for providers and plans, Focus Care takes managed care one step further, in an effort to maximize your business success. Driven by our commitment to revenue optimization and efficient member service, Focus Care delivers a network of nursing utilization methods unmatched in the industry.

Quality Assurance Specialist (RN) – Health Risk Assessments Position: Part-Time (up to 25 hours per week) License Required: Active RN Experience: HRA QA, CMS/NCQA, Risk Adjustment, Case Management, Home Care Location: Remote About the Role: Focus Care, Inc. is seeking an experienced Registered Nurse to join our Quality Assurance team. The QA Specialist is responsible for reviewing Health Risk Assessments (HRAs) completed by NPs and PAs to ensure clinical accuracy, coding compliance, and alignment with CMS, NCQA, and payer-specific guidelines. This role directly supports documentation quality, regulatory compliance, and organizational performance.

Conduct QA audits of HRAs with 24-hour turnaround. Validate ICD-10/HCC coding for accuracy using MEAT criteria. Ensure compliance with CMS, NCQA, HIPAA, and internal P&P. Identify under/over-utilization trends in risk adjustment. Monitor workflows and productivity metrics. Provide clear, constructive feedback to clinicians. Analyze QA data to identify trends and opportunities for improvement. Use systems such as Focus Care to support workflow and HCC capture. Contribute to policy updates, quality improvement, and care transition strategies. Stay current on risk adjustment, coding guidelines, and regulatory changes.