Quality Improvement Specialist Sr

About the role

The Senior Quality Improvement Specialist coordinates assigned regulatory, accreditation, clinical quality and/or service improvement programs. Functions as a leader for health services initiatives handling multiple large-scale complex initiatives. Collaborates on national, regional and multi-plan initiatives. Develops programs in compliance with accreditation and regulatory requirements/standards and monitors ongoing program performance to maintain compliance. Acts as a resource for training, policy and regulatory/accreditation interpretation.

Responsibilities

• Leads and manages multiple complex initiatives that impact the quality or effectiveness of health care delivery and/or health care services provided to members.
• Ensures that clinical and service quality improvement programs and initiatives are compliant with applicable accreditation, state and federal requirements.
• Conducts an assessment of programs, initiatives and interventions to ensure goals and objectives were met and refine activities, as needed, to improve the effectiveness and improve outcomes.
• Conducts vendor oversight and management.
• Develops targeted activities to improve Star Ratings, HEDIS, CAHPS, HOS, provider satisfaction and other identified performance measures.
• Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas.
• Participates in the development and maintenance of annual quality improvement program documents and evaluations, compliance audits, policies and procedures, and improvement activities.
• Develops internal reports to demonstrate progress on each initiative/project and presents to senior-level staff.
• Describes outreach initiatives, potential/experienced barriers and activities to resolve issues and improve outcomes.
• Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management.
• Identifies areas of improvement within the company and works collaboratively with other departments to develop clinical and non-clinical performance improvement projects.
• Researches best practices, national and regional benchmarks, and industry standards.
• Develops collaborative relationships with contracted providers or provider groups to promote participation in quality improvement collaboratives to improve clinical care outcomes.
• May lead and/or participate in external activities, work groups or committees when applicable.
• Communicates programs, interventions and results to external entities in accordance with applicable program objectives, policies and procedures.
• Develops and/or maintains relationships with other external organizations to expand key partnerships.
• Assesses current industry trends and regulations for enterprise-wide adoption to assure quality and effectiveness of health care delivery and/or healthcare services provided to members.
• Performs all other duties as assigned.

Qualifications

• Education: Bachelor's Degree or equivalent experience with clinical license, or Master's Degree in related health field (i.e. MPH or MPA).
• Valid state clinical license preferred.
• Certified Professional in Health Care Quality (CPHQ) preferred.
• Minimum three years experience in a clinical/health care environment with related degree program.
• Three to five years managed care experience in a health care environment.
• Experience in compliance, accreditation, service or quality improvement.
• Complex project management experience.
• Experience with Medicare and/or NCQA preferred.

Pay

$70,100.00 - $126,200.00 per year. 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

• 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