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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.
Manages and 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 concerns 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.
Assists in implementation of market specific strategies that improve on the quality and outcomes of member's care.
Represents supervisors and management in meetings or on special assignments.
Helps establish process improvements leading to best practice and assist in implementing change management.
Trains, mentors and provides guidance to new and current Quality Improvement Specialists regarding policy and procedure, systematic tools, workload and best practices.
Analyzes, updates, and modifies procedures and processes to continually improve QI operations.
Collects and summarizes performance data, identify opportunities for improvement, and present findings to Quality Improvement Committees.
Leads and facilitates quality improvement teams in the development of QIPs, PIPs and QIAs
Serves as knowledge expert for continuous quality improvement activities.
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 the Licensed Health Care Risk Management certification program.
Performs annual update on 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
Preferred A Master's Degree in a related field
Required 4 years of experience in directly related Quality Improvement job function duties
Required 5 years of experience in Managed Care
Required Other Experience in compliance and accreditation
Required Other Knowledge of federal and state regulations/requirements
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
Advanced Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate Knowledge of community, state and federal laws and resources
Advanced Knowledge of healthcare delivery
Advanced Ability to implement process improvements
Advanced Ability to influence internal and external constituents
Licenses and Certifications:
Required Intermediate Microsoft Excel
Required Intermediate Healthcare Management Systems (Generic)