Quality Improvement Specialist (Albany/Hudson Valley)
WellCare - Manhattan, NY

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About WellCare: WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Florida, WellCare offers a variety of health plans for families, children, and the aged, blind, and disabled, as well as prescription drug plans. For more information about WellCare, please visit the Company's website at www.wellcare.com.

Our History: Founded in 1985 with three associates, WellCare grew to more than 800 associates and 467,000 members in Florida, New York and Connecticut by 2002. In 2004, the company acquired Harmony to enter the Midwest and became publicly traded. By 2006, WellCare served 2.2 million members as it became a national prescription drug plan provider and the largest Medicaid plan in Georgia. WellCare expanded its services when it began offering Medicaid managed care plans in Ohio and Missouri in 2007, and Medicare managed care plans in Texas and New Jersey in 2008. Additional growth followed when the company was chosen to serve Hawaii's Medicaid program for the aged, blind or disabled in 2009, and in 2011 when it was selected to serve Kentucky's Medicaid program. Today, WellCare has more than 3,900 associates and approximately 2.4 million members nationwide.

EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.


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.

Essential Functions:
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.

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 effect 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.

Assist with training for new associates.

Performs other duties as assigned.


Completes the Florida Licensed Health Care Risk Management certification program.

Performs annual update on Florida Plan Risk Management Program Description.

Coordinates the regular and systematic review of all potential adverse incidents in accordance with Florida statute s. 641.55.

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 Florida Plan quality committee structure and Board of Directors.


A Bachelor's Degree in Healthcare, Nursing, Health Administration, related health field or equivalent work experience. Master's Degree in Healthcare preferred.

2+ years clinical experience with clinical degree program. 3-5 years managed care experience. Experience in compliance, accreditation, service or quality improvement. Knowledge of accreditation, federal and state regulations/requirements

Licensed Registered Nurse

Special Skills (e.g. 2


Excellent communication skills required

Ability to communicate effectively with people with varying levels of education

Ability to multitask in a fast paced environment

Technical Skills/Requirements:
Proficient in Microsoft Office such as Excel, Access, PowerPoint and Outlook

Primary Location



Yes, 20 % of the Time

Is a relocation package available?


WellCare - 2 years ago - save job
About this company
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WellCare knows that to get well, all you need is a little care. WellCare Health Plans provides managed-care administrative services to...