Conducts oversight and management of Accreditation initiatives, state and regulatory quality compliance, HEDIS and quality improvement initiatives for PiPs, QiPs, QIA's, delegation audits and external quality reviews . Applies medical knowledge and analytical skills to effectively and efficiently coordinate quality activities and improve performance metrics of organizational goals.
DEPARTMENT: Health Services-Quality Improvement
REPORTS TO: Sr. Director, Field Health Services
- Develops, implements and maintains a standardized quality management plan and program to ensure compliance with external regulatory and accreditation requirements.
- Establishes and maintains tracking and monitoring systems for health care quality improvement activities according to regulatory requirements, accreditation standards, policies and procedures and contractual agreements.
- Ensures high risk, high volume, and unusual events are monitored concurrently and retrospectively as they occur.
- Researches and develops performance measurement and outcome studies to assess and improve the health status of the membership. Plans, organizes and manages the design, development and analysis of a wide variety of topics relevant to health care services.
- Designs and develops methodologies for preventive care and health care evaluations. Researches and documents current health care standards for use in study design and methodologies. Conducts preventive studies to evaluate the continuity and coordination of care and to assess the quality and utilization of health care services. Provides assistance and guidance to clinical staff with regard to study design, methodology, data analysis and reporting.
- Manages and evaluates performance of staff related to clinical and health care services performance improvement activities. Provides department orientation to new staff and ongoing staff development to the entire department.
- Coordinates guidelines, studies and performance improvement activities in concert with the utilization management, quality management, pharmacy services, case management and disease management programs.
- Maintains a knowledge base of HEDIS requirements and implementing clinical performance methods to improve HEDIS performance.
- Prepares, compiles, reviews and submits monthly and quarterly reports for quality committee meetings.
- Coordinates all external programmatic oversight visits for contracted providers and ensures timely completion and follow up on corrective action plans.
- Participates in the development, review and updating of policies and procedures.
- Develops and analyzes reports to monitor and evaluate quality performance in meeting established goals related to quality improvement plan and contractual requirements.
- Provides guidance and training to new associates.
- Performs other duties as assigned.
- Completes the state Licensed Health Care Risk Management certification program.
- Performs annual update on state Plan Risk Management Program Description.
- Coordinates the regular and systematic review of all potential adverse incidents in accordance with state statute.
- Completes AHCA Code 15 Reports for confirmed adverse incidents.
- Submits an annual AHCA adverse incident summary report.
- Presents summary reports of reported AHCA Code 15 adverse incidents through the state Plan quality committee structure and Board of Directors.
*LI-SM1 Candidate Education:
- Required a Bachelor's Degree in Healthcare, Nursing, Public Health, Health Administration or directly related degree or equivalent work experience
- Preferred a Master's Degree in Healthcare
- Required 5 years of experience in directly related Quality Improvement job duties
- Required 3 years of experience in managed care
- Required 1 year of management experience
- Required excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards
- Preferred experience with Medicaid/Medicare
Licenses and Certifications:
- Intermediate knowledge of community, state and federal laws and resources
- Advanced demonstrated written communication skills
- Advanced demonstrated interpersonal/verbal communication skills
- Advanced demonstrated analytical skills
- Advanced demonstrated problem solving skills
- Intermediate ability to work in a fast paced environment with changing priorities
- Intermediate ability to multi-task
- Advanced ability to effectively present information and respond to questions from families, members, and providers
- Advanced ability to effectively present information and respond to questions from peers and management
- Intermediate ability to influence internal and external constituents
- Intermediate ability to lead/manage others
A license in one of the following is required:
- Required for IL/MO RN License
- Preferred Licensed Registered Nurse (RN)
- Preferred Certified Professionals in Healthcare Quality (CPHQ)
- Required intermediate Microsoft Excel
- Required intermediate Microsoft Word
- Required intermediate Microsoft Visio
- Required intermediate Microsoft PowerPoint
- Required intermediate Microsoft Outlook
- Required intermediate Healthcare Management Systems (Generic)