Clinical Quality Specialist - Peak Health

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MINIMUM QUALIFICATIONS:

EDUCATION, EXPERIENCE, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) AND Four (4) years of healthcare clinical experience.

OR

2. Bachelor’s degree in healthcare or business-related field AND Six (6) years healthcare quality management or performance improvement in a health plan, hospital, or physician practice.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

EXPERIENCE:

1. Managed Care knowledge or experience

2. Three (3) years Quality Management, Quality Improvement or Process Improvement Experience.

3. Knowledge of CMS guidelines, regulations, NCQA® and HEDIS®.

4. Thorough knowledge of Performance Improvement Projects (PIPs) and is able to apply that knowledge in PIP writing development, update, and analysis of data in PIPs.

5. Able to work with large data sets and analyze information and provide recommendations.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Plan, design, implement, and maintain a comprehensive program of continuous quality improvement (CQI) through HEDIS compliance rate tracking, trending and analysis as well as identifying existing challenges, inefficiencies and areas in need of improvement or intervention3. Assume accountability for HEDIS/Stars improvement activities including medical record review, chart collection, and member or provider interventions or education to improve HEDIS compliance rates for Medicare HEDIS/STARS measures.

4. Assist in preparing the annual QI evaluation report and plan/program documents.

5. Review medical records and other documentation to ensure quality care is being provided.

7. Ensure workflows, policies, procedures, regulatory and accreditation standards are implemented and maintain compliance for clinical programs.

8. Investigate potential quality of care issues that may affect the quality or safety of the health of members

9. Evaluate reports for continued compliance with clinical quality requirements.

10. Actively participate in quality committee, assist in developing annual work plans, program descriptions, and evaluations.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.Standard office environment

SKILLS AND ABILITIES:

1. Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, URAC, and/or NCQA accreditation standards, including HEDIS/STARS.

2. Excellent written and oral communication

3. Problem solving capabilities to drive improved efficiencies and customer satisfaction

4. Attention to detail

5. Proficiency with Microsoft Office

6. Medicare experience preferred

7. Remote for the most part, will have expectations to come in on as-needed basis

Additional Job Description:

MUST HAVE HEDIS EXPERIENCE

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center: