Develop and coordinates quality improvement activities and interventions with the goal to improve the health of our customers and the healthcare services of our providers. Assigned projects may include but are not limited to areas of patient safety, medical record review, quality reviews, clinical complaint resolution, health care data collection, coordination of care, provider education and participation in local or state coalitions. Participates on health improvement internal and external teams. Activities are aligned with meeting corporate goals, National Committee for Quality Assurance, Department of Health and, Centers for Medicare and Medicaid Services standards.
Primary Job Duties:
- Plan, implement and evaluate assigned projects in areas such as preventive health, coordination of care, medical record review, quality review, regulatory review preparation, provider and member education, etc. Responsible for creating and implementing required Quality Improvement programs.
- Responsible for submitting accurate reports on the status of programs. Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance with company procedures. Assists in defining opportunities for improvement identified through analysis of trends and barriers, and communicates these appropriately.
- Participates in HEDIS medical record activities. Assists with coordinating HEDIS Improvement activities. Or, as applicable, coordinates resolution of member complaints or quality investigations, related to quality care provided by facilities or health care providers.
- Conducts documentation reviews of providers as needed, in order to meet regulatory requirements and standards.
- Participates in Quality Assurance activities, as directed. Actively participates in intradepartmental quality management improvement teams as appointed. Conducts, as appropriate, oversight audits for delegated vendors.
- Recommends program/service changes to meet gaps in service in the community and/or patient care.
- Responsible for maintaining quality management documents, case files and correspondence in an organized, confidential and secure manner. Documents in a compliant and comprehensive manner.
- Performs other related duties as requested.
- Registered Professional Nursing License or NYS recognized Qualified Health Care professional (ex. Licensed or certified CRC, CSW, PhD, OT, PT) required
- Previous Health Plan experience preferred
- Advanced proficiency in MS Excel, basic proficiency in MS Office applications
- Excellent time management skills
- Project management skills
- Excellent organizational skills and attention to detail
- Excellent verbal and written communication skills
- Strategic thinking/planning skills; must possess creative and critical independent thinking to take charge of assigned projects and the ability to work effectively with minimal supervision and oversight.
- Ability to work effectively with minor supervision
- Prior experience in a fast-paced face-to-face customer service role working with daily deadlines and interruptions required
- High degree of business maturity and demonstrated confidentiality
- High energy level and ability to project enthusiasm
- Demonstrated change management and change catalyst competencies
- Demonstrated personal accountability
- Able to work with individuals and teams to meet common goals as well as being self directed
- Knowledge of local and national QM and regulatory standards preferred, including NCQA and HEDIS reporting.
- MS Office
Must be Qualified Healthcare Professional. Bachelors degree with minimum 3 years clinical work experience. BSN preferred.
Associates degree with minimum 5 years clinical work experience required.
- Must be able to work in an office environment
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
- Qualified Healthcare Professional
HealthNow New York Inc. - 20 months ago
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