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 analytic and reporting activities.
Department: Quality Improvement
Reports to: Sr Dir, Quality 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.
- Monitors and investigates all quality of care and collaborates with medical directors to determine impacts and next steps for actions. Monitors provider quality complaints to identify trends and educational opportunities for improvement.
- Analyzes, updates, and modifies procedures and processes to continually improve QI operations.
- Collects and summarizes performance data and identifies opportunities for improvement.
- Serves as knowledge expert for continuous quality improvement activities, QIPS, PIPs and QIAs.
- 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.
- Supports the implementation of the quality reporting infrastructure.
- 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.
- Assists in activities to prioritize clinical and service improvement initiatives.
- 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.
- 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.
- Required A High School or GED with a current unrestricted RN license
- Preferred A Bachelor's Degree in Healthcare, Nursing, Health Administration, Public Health or related health field
- Required 2 years of experience in Quality Improvement
- Required 3 years of experience in Managed Care
- Required Other Experience in compliance and accreditation
- Required Other Knowledge of federal and state regulations/requirements
Licenses and Certifications:
- Advanced Demonstrated written communication skills
- Advanced Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Advanced Ability to create, review and interpret treatment plans
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Knowledge of healthcare delivery
- Intermediate Knowledge of community, state and federal laws and resources
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Ability to implement process improvements
- Required - Licensed Registered Nurse (RN)
- Required Intermediate Microsoft Excel
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook