Job #: 1695

Title: Clinical Quality Improvement

Salary Range:
  • $75,000 to $100,000

  • Contract Pay Rate:
  • $0-25
    • Anywhere
    • Posted 10 months ago
    • This position has been filled

    Position Overview

    The primary function of the Clinical Quality Improvement Specialist is to design, implement and evaluate complex quality and process improvement projects required to support public health, HEDIS, QARR, Stars and other regulatory needs for complex chronic care conditions. These functions are carried out in a cost effective and measurable design model.

    Scope of Role & Responsibilities (URAC Core 25d)
    Design, implement and evaluate complex quality and process improvement projects required to support public health, HEDIS, QARR, Stars and other regulatory needs to drive specific clinical quality improvement outcomes.

    Research, develop and identify internal and external barriers/root causes that affect the health status of plan members and ensure the implementation of strategies to overcome these barriers.
    Develop methods and/or tools to collect and track barriers for targeted members and providers. Methods may include but not be limited to surveys, focus groups, visits to provider offices/hospitals, community events or healthcare organizations.
    Create plans/interventions based on barrier, data, and/or competitor analyses, defined project scope and goals, measurable metrics for program evaluations, and projected timelines.
    Develop member and provider communications that are clear, direct and actionable.
    Apply analytics to identify and target various populations to drive quality improvement and measurable outcomes.
    Evaluates interventions for project/intervention continuation and or modification to provide for continuous process improvement.
    Develops tools and supports for the physicians, provider groups, etc. relative to measures/desired outcomes for specific diseases to drive quality improvement.
    Document findings for each initiative and presents results to applicable departments and management.
    Analyze member and provider data for assigned healthcare quality measures and/or population to identify trend and target population/area for quality improvement projects. Data sources and tools may include but not be limited to the following:
    Statistical significant changes in rates/stratifications
    Member and provider information from government and vendor’s reports and datasets and internal databases.
    Actively participate with other departments to coordinate and meet CMS, DOH, HEDIS, URAC and other agencies accreditation and regulatory standards. Participate in identification of network needs and best practice benchmarks in relation to quality improvement initiatives. Align resources utilizing maximum effectiveness and efficiency.
    Participate with other departments to create and implement corrective action plans as required by DOH/article 44 audit.
    Management of Quality and Performance Improvement Project(s) up to and including documenting performance indicators, outcomes measures, process measures, procedures, interventions and reporting to CMS/ DOH/IPRO.
    Develop and maintain positive business relationships with community organizations, pharmaceutical companies, regulatory agencies and others to promote  involvement with health status improvement within the community and to facilitate excellent customer service and process improvement.
    All other duties as assigned at the discretion of Quality Management Leadership.

    Required Education, Training & Professional Experience: (URAC Core 25a)
    Bachelor’s degree in a clinical field required. Advanced degree preferred.
    Current licensed RN (preferred) or LPN with minimum of 4-6 years of clinical experience.
    Must have a minimum of 5 years’ experience in the health care field.
    Quality Improvement experience in a managed care environment preferred.
    Must be proficient in Microsoft Word, PowerPoint, Excel and Access.
    Experience with and proficient in data analysis. Working knowledge of relational database and statistical analyses is a plus.
    Must be familiar with and have a working knowledge with QI process improvement methodology strategies including but not limited to PDSA and DMAIC.
    Must be familiar with the HEDIS, QARR requirements.
    Must possess analytical skills in order to collect, organize and present data in a clear and concise manner.
    Ability to assess all work and prioritize as necessary to meet reporting timeframes and deadlines.
    Six Sigma Yellow or Green Belt preferred.

    Licensure and/or Certification Required: (URAC Core 25c)
    Bachelor’s degree in a clinical field required. Advanced degree preferred.
    Current licensed RN (preferred) or LPN with minimum of 4-6 years of clinical experience.

    Professional Competencies: (URAC Core 25b)
    Superior oral, written and communications skills. Ability to understand and communicate analytic and clinical data to varied audiences.
    Solid analytical and logical skills paired with strong attention to details.
    Must be a versatile, quick learner, who is open to change and enjoys the challenge of unfamiliar tasks.
    Superior project management and documentation skills.
    Must be action oriented, producing results on projects that require risk taking with minimal planning, while keeping self-control during high activity periods.
    Ability to function well independently and in team setting.
    Must be able to make effective and timely decisions by organizing information in a useful manner and orchestrating multiple activities at once to accomplish the goal.
    Must work effectively with others, fostering open dialogue, accountability and common mindsets within the team.
    Must have integrity, fostering an honest and trusting relationship with co-workers and management, never compromising the Plan, other employees or self for personal gain.
    Must seek to continuously improve processes for the benefit of the customer by taking personal responsibility for the resolution of customer services.