Clinical Quality Specialist

WVU Medicine

13d • Remote

About The Position

The Clinical Quality Specialist will be an integral member of the Peak Health’s quality team. This position is responsible for overseeing performance improvement activities, ensuring regulatory compliance, and other initiatives that lead to effective improvements in quality. In this role you will support the HEDIS program by assisting with medical record retrieval and abstraction, working closely with providers to ensure accurate and complete documentation and collaborating with the HEDIS Program Manager and Quality Manager to implement performance improvement initiatives. Additionally, the Clinical Quality Specialist will be involved in performance monitoring and assessment and gathering and analyzing data to evaluate outcomes.

Requirements

• 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.
• 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.
• Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, URAC, and/or NCQA accreditation standards, including HEDIS/STARS.
• Excellent written and oral communication
• Problem solving capabilities to drive improved efficiencies and customer satisfaction
• Attention to detail
• Proficiency with Microsoft Office

Nice To Haves

• 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.
• Managed Care knowledge or experience
• Three (3) years Quality Management, Quality Improvement or Process Improvement Experience.
• Knowledge of CMS guidelines, regulations, NCQA® and HEDIS®.
• 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.
• Able to work with large data sets and analyze information and provide recommendations.
• Medicare experience preferred

Responsibilities

• 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.
• Assist in preparing the annual QI evaluation report and plan/program documents.
• Review medical records and other documentation to ensure quality care is being provided.
• Ensure workflows, policies, procedures, regulatory and accreditation standards are implemented and maintain compliance for clinical programs.
• Investigate potential quality of care issues that may affect the quality or safety of the health of members
• Evaluate reports for continued compliance with clinical quality requirements.
• Actively participate in quality committee, assist in developing annual work plans, program descriptions, and evaluations.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level