Skip to main content
Health Services
WellCare - Nursing Careers

Quality Improvement Manager - RN Job

Full Job Title: Manager, Quality Improvement - RN*

Job Number: 1703695

Location: Springfield, IL

Date Posted: 8-10-2017

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

Essential Functions:

  • 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.
Additional Responsibilities:
  • 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
Candidate Experience:
  • 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
Candidate Skills:
  • 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
Licenses and Certifications:
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)
Technical Skills:
  • 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)

Languages:

  • Bilingual helpful

Back to top

Join Our
Talent Network

and receive job alerts
Click Here
Last Updated On: 12/9/2015