Quality Improvement Specialist

Job Responsibilities

• Actively demonstrates the organization’s mission and core values and conducts oneself at all times in a manner consistent with these values.
• Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information.
• Collaborates with appropriate management and departments to establish clear objectives, indicators and action plans; monitors progress and results to assure overall effectiveness and meeting of targets.
• Affords coordination assistance directly related to key quality improvement (QI) activities and projects.
• Coordinates with provider offices to gather data and perform chart review as needed.
• Collects data from one or more sources including encounters, claims, and other data sources to improve identified quality outcomes and population health goals.
• Evaluates reports for accuracy.
• Maintains the integrity of the data by entering information into the appropriate quality documentation system.
• Assists in the planning, coordination, and evaluation of QI learning and education sessions related to quality initiatives.
• Completes member outreach to close gaps in care.
• Maintains quality customer service at all times with patients, exhibiting courteous and professional behavior.
• Understands and stays up to date with current HEDIS measures.
• Prepares routine reports and other ad-hoc reports utilizing disparate systems.
• Performs comparisons to external and internal benchmarks to identify opportunities for improvement in quality indicators.
• Maintains a working knowledge of each product including, but not limited to, benefit plans, limitations, and additions.
• Supports and assists the Quality Improvement Manager in the implementation of QI projects and activities.
• Accomplishes workload timely to meet reporting requirements.
• Participates in the development of policies and procedures related to quality initiatives and possesses the ability to evaluate current processes for enhancement and make necessary recommendations for improvement.
• Provides support for Best Practice implementations at the physician practices.
• Assists with chart reviews and quality auditing.

Requirements

• Knowledge of a wide range of clinical areas and medical terminology normally acquired by completing a Bachelor’s degree in a clinical area.
• Experience in data mining and analysis in a managed care setting.
• Knowledge of performance improvement measurement systems and the metrics used to assess performance.
• Experience in Quality Improvement and/or Case Management is preferred.
• Computer proficient and appropriate telephone etiquette skills required.
• One year of managed care experience preferred.