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Supports the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies that impact plan compliance to regulatory and accreditation standards. Drives key quality improvement projects requiring the ability to work effectively in a matrix environment in order to receive needed data that reflects the overall health of the plan.
Reports to: VP, Pharmacy Clinical Programs
Establishes and/or revises existing WellCare policies and procedures necessary for successful implementation of the Quality Improvement (QI) Program.
Pursues methods to ensure receipt of relevant data, as required for accurate trending of various QI work plan metrics.
Analyzes key plan metrics, such as top diagnoses, clinical procedures, and operational performance, to enable the development of sound and valid recommendations regarding and prioritization of clinical and service improvement initiatives.
Works with QI Director to convene various QI committees and work groups, set agenda to drive desired meeting outcomes (based on contract and accreditation requirements), and ensure proper recording of committee activities.
Acts as knowledge expert for continuous quality improvement activities, educating staff of other functional areas regarding the QI process and accreditation requirements.
Performs various quality department functions and processes, such as quality of care complaint/adverse event review and assessment of medical record review results and recommend actions to address any identified improvement opportunities.
Manages and monitors clinical quality studies to include receipt and analysis of trended data, assessment of national benchmarks as available, development of improvement recommendations (to include ROI and best practice interventions as appropriate), presentation to senior leadership, implementation of plan, and evaluation for desired result.
Recommends strategies to improve member compliance to QI program activities, addressing methods to change knowledge, attitudes and behaviors, such as handbook content, newsletter articles, member outreach interventions, and member focus groups.
Recommends methods to improve network provider compliance to health plan QI Program policies and procedures, including profiles/scorecards and efforts to increase provider compliance to practice guidelines, such as through medical record review.
Fields annual member and provider satisfaction surveys, working with vendor to clarify results and present findings and recommendations to senior leadership.
Assists with efforts to secure successful NCQA accreditation.
Performs activities to comply with annual HEDIS data collection and analysis, preparing recommendations to increase rates as appropriate.
Participate in site visit preparation and execution by various regulatory and accreditation agencies (DCH, DHR, CMS, EQRO).
Monitors and tracks all state and federal quality improvement and reporting requirements.
Supports efforts to submit monthly, quarterly, semi-annual, and annual regulatory required performance reports.
Assists in developing short range plans for overall area activities.
Develops and oversees the implementation of programs and strategies .
Acts in liaison capacity with other areas and business units.
Makes recommendations on matters of policy in area of expertise.
Performs other duties as assigned.
Required A Bachelor's Degree in nursing or a related health field or equivalent years of related experience.
Required A Master's Degree in a related field may be considered in lieu of experience
Required 5 years of experience in a health care delivery organization, such as a managed care organization or a hospital environment
Required 3 years of experience in QI, performing a wide range of functions with strong focus on data analysis and initiation of improvement initiatives that resulted in desired outcome
Required 3 years of experience in process improvement and project management
Required Other Knowledge of Medicaid and/or Medicare programs
Intermediate Demonstrated organizational skills
Intermediate Ability to work in a fast paced environment with changing priorities
Intermediate Ability to multi-task
Intermediate Other Knowledgeable of current trends in quality improvement in managed health care
Intermediate Other Knowledgeable of DCH, DHR and CMS regulatory requirements
Intermediate Other Knowledgeable of JCAHO, NCQA, HEDIS and CAHPS requirements
Intermediate Other Ability and confidence to make decisions based on scope of the job
Intermediate Other Ability to work on multiple projects and tasks on a daily basis, remaining calm under pressure
Intermediate Other Ability to be flexible in the face of changing priorities
Intermediate Other Ability to work effectively across departmental lines