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WellCare - Nursing Careers

Quality Improvement Specialist - Associate Job

Full Job Title: Quality Improvement Specialist, Associate

Job Number: 1705493

Location: Oahu, HI

Date Posted: 11-15-2017

Supports the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies impacting plan compliance to regulatory and accreditation standards. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytics and reporting activities.




Essential Functions:

  • Monitors and investigates all quality of care concerns and collaborates with medical director to determine impact and next steps for actions. Monitors provider quality complaints to identify trends and educational opportunities for improvement.
  • Monitors quality improvement initiatives including, but not limited to, development and implementation of preventive health and chronic disease outcome improvement interventions such as: newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys.
  • Analyzes, updates, and modifies procedures and processes to continually improve QI operations.
  • Collects and summarizes performance data and identifies opportunities for improvement.
  • Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met.
  • Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA, EQRO).
  • Conducts internal auditing of compliance with regulatory and accreditation standards.
  • Pursues methods to ensure receipt of data required for trending and reporting of various QI work plan metrics, performs adequate data/barrier analysis, develops improvement recommendations, and deploys actions as approved.
  • Participates in various QI committees and work groups convened to improve process and/or health outcomes, and contributes meaningful detail, based on functional knowledge. Completes follow-up as assigned.
  • Manages and monitors assigned quality studies.
  • Investigates and incorporates national best practice interventions to affect greater rate increases.
  • Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
  • Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
  • Performs other duties as assigned.
Additional Responsibilities:
  • Completes Licensed Health Care Risk Management certification program.
  • Performs annual update on 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 quality committee structure and Board of Directors.
Candidate Education:
  • High School or GED with a current unrestricted RN license is required
  • Bachelor's Degree in Healthcare, Nursing, Health Administration, Public Health or related health field is preferred
Candidate Experience:
  • 3 years of experience in a clinical acute care, case management, disease management, clinical compliance, public health, home health or clinical nurse position is required
  • 2 years of experience in Managed Care is required
  • Knowledge of federal and state regulations/requirements is required
  • 1 year of experience in Quality Improvement is preferred
  • Experience in compliance and accreditation is preferred
Candidate Skills:
  • Demonstrated written communication skills
  • Demonstrated interpersonal/verbal communication skills
  • Ability to multi-task
  • Ability to work in a fast paced environment with changing priorities
  • Ability to effectively present information and respond to questions from families, members, and providers
  • Ability to create, review and interpret treatment plans
  • Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Knowledge of healthcare delivery
  • Knowledge of community, state and federal laws and resources
  • Demonstrated time management and priority setting skills
  • Ability to implement process improvements


  • Registered Nurse License (RN) is required
Technical Skills:
  • Microsoft Excel is required
  • Healthcare Management Systems (Generic) is required
  • Microsoft Word is required
  • Microsoft Outlook is required

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Last Updated On: 12/9/2015