Quality Improvement Specialist

About the Role

Monitors and investigates all quality of care concerns and collaborates with the medical director to determine impact and next steps for actions. Supports the development and implementation of quality improvement interventions and audits, and assists in resolving deficiencies impacting plan compliance to regulatory and accreditation standards. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytics and reporting activities.

Responsibilities

• Monitors provider quality complaints to identify trends and educational opportunities for improvement.
• Monitors quality improvement initiatives including development and implementation of preventive health and chronic disease outcome improvement interventions such as: newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys.
• Analyzes, updates, and modifies procedures and processes to continually improve QI operations.
• Collects and summarizes performance data and identifies opportunities for improvement.
• Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation, and regulatory requirements are met.
• Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA, EQRO).
• Conducts internal auditing of compliance with regulatory and accreditation standards.
• Pursues methods to ensure receipt of data required for trending and reporting of various QI work plan metrics, performs adequate data/barrier analysis, develops improvement recommendations, and deploys actions as approved.
• Participates in various QI committees and work groups convened to improve process and/or health outcomes, contributing meaningful detail based on functional knowledge.
• Completes follow-up as assigned.
• Manages and monitors assigned quality studies.
• Investigates and incorporates national best practice interventions to affect greater rate increases.
• Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
• Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
• Completes Licensed Health Care Risk Management certification program.
• Performs annual update on Plan Risk Management Program Description.
• Coordinates the regular and systematic review of all potential adverse incidents in accordance with state statute.
• Performs other duties as assigned.

Requirements

• A license in one of the following is required: Licensed Registered Nurse (RN).
• High School diploma or GED with a current unrestricted RN license.
• Bachelor's Degree in Healthcare, Nursing, Health Administration, Public Health, or related health field (Preferred).
• 2+ years of experience in Quality Improvement (Required).
• 3+ years of experience in Managed Care (Preferred).
• Experience in Compliance and Accreditation (Required).
• Knowledge of Federal and State regulations/requirements (Required).

For Ohana Health Plan only: Associate's Degree required; must be a Licensed RN in the state of Hawaii.

Pay

$56,200.00 - $101,000.00 per year

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible approach to work with remote, hybrid, field, or office work schedules

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.