Quality Perform Specialist Clinical

Responsibilities

• Leading and coordinating the clinical quality review process of member concerns and medical records utilizing standards of care.
• Supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines.
• Supporting accreditation and clinical quality performance improvement activities.
• Assuming responsibility for performing quality of care reviews to include all sentinel events and member concerns.
• Cooking reviews with physician advisors and clinical quality committees as appropriate.
• Assuring minimally necessary medical records are collected and organized for clinical review to occur.
• Assists with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets, schedules, agendas, and the review and approval of minutes.
• Reviews and approves the QM work plan on an annual basis including selection of performance measures, goals, objectives, and thresholds.
• Develops QOC quarterly trending reports for QAPI for input and direction.
• Follows up on any recommendations.
• Adheres to QM policies including annual reviews, updates, and approvals.
• Participates and assists in activities and reporting to maintain compliance with state regulations and NCQA standards for quality activities.
• Supports the quality improvement department with annual medical record review activities including HEDIS, NCQA and Clinical Practice Guidelines by working collaboratively with the Quality Improvement Department.
• Assistance will be based upon the organizations needs annually but may include participation in the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.
• All other duties as assigned.

Requirements

• Associate’s Degree or equivalent work experience, Bachelor’s Degree preferred.
• Minimum of 3 years in clinical or service quality improvement/ health care delivery or relevant experience required.
• An unrestricted Clinical license (RN) in the plan’s state or any other state he/she works required.
• Prior experience with project facilitation/management preferred.
• Knowledge and understanding of QI functions in an MCO preferred.
• Knowledge of Medicaid and Medicare preferred.
• Proficient with Microsoft Office applications including Word, PowerPoint, Excel required.

Qualifications

• Strong maternal and / or women's health background strongly preferred.

Skills

• Project Facilitation/Management
• Quality Improvement
• Microsoft Office Applications

Benefits

• Flexible work solutions including remote options, hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement
• More benefits available