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: Director, Quality Improvement
- 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, Nursing, Public Health, Health Administration
- 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)