Quality Improvement Specialist Senior
About The Position
The Senior Quality Improvement Specialist coordinates assigned regulatory, accreditation, clinical quality, and service improvement programs and leads multiple large-scale, complex health services initiatives. The role collaborates on national, regional, and multi-plan initiatives; develops programs in compliance with applicable standards; monitors ongoing performance; and serves as a resource for training and interpretation of policy, regulatory, and accreditation requirements. A primary focus is leading Medicaid state withhold and pay-for-performance programs. This includes interpreting contractual requirements and performance targets; developing and monitoring measure-level action plans, interventions, reporting, and financial impact; and coordinating with cross-functional teams, executive leadership, and state partners to achieve required outcomes. The specialist leads and evaluates quality and service improvement initiatives, oversees vendors, develops targeted activities to improve performance measures, and prepares communications, reports, and materials for internal and external stakeholders. The role also supports annual quality program documents, evaluations, compliance audits, policies, and improvement activities; identifies improvement opportunities; researches industry practices and benchmarks; and builds collaborative relationships with providers and external organizations. The position requires a bachelor’s degree or equivalent experience with a clinical license, or a master’s degree in a related health field. A valid state clinical license and Certified Professional in Health Care Quality (CPHQ) certification are preferred. Applicants should have at least three years of clinical or health care environment experience with a related degree program, three to five years of managed care experience, experience in compliance, accreditation, service or quality improvement, and complex project management experience. Medicare and/or NCQA experience is preferred.
Requirements
- Bachelor’s degree or equivalent experience with a clinical license, or a master’s degree in a related health field such as MPH or MPA.
- Minimum of three years of experience in a clinical or health care environment with a related degree program.
- Three to five years of managed care experience in a health care environment.
- Experience in compliance, accreditation, service improvement, or quality improvement.
- Complex project management experience.
Nice To Haves
- Valid state clinical license.
- Certified Professional in Health Care Quality (CPHQ) certification.
- Experience with Medicare and/or NCQA.
Responsibilities
- Lead and manage multiple complex initiatives affecting the quality or effectiveness of health care delivery and services provided to members.
- Lead Medicaid state withhold and pay-for-performance programs, including interpreting contractual requirements and performance targets and coordinating action plans, interventions, reporting, and financial impact.
- Ensure clinical and service quality improvement programs comply with applicable accreditation and state and federal requirements.
- Assess programs, initiatives, and interventions against goals and objectives, and refine activities to improve effectiveness and outcomes.
- Conduct vendor oversight and management.
- Develop targeted activities to improve Star Ratings, HEDIS, CAHPS, HOS, provider satisfaction, and other identified performance measures.
- Develop and implement project communications, including member and physician mailings, IVR scripts, emails, business plans, and graphics; maintain agendas and minutes.
- Participate in developing and maintaining annual quality improvement program documents and evaluations, compliance audits, policies and procedures, and improvement activities.
- Develop internal reports showing initiative and project progress, and present findings to senior-level staff.
- Describe outreach initiatives, barriers, and activities to resolve issues and improve outcomes.
- Lead or participate in multi-department and cross-functional committees and work groups, preparing reports, data, agendas, minutes, and other presentation materials.
- Identify opportunities for improvement and collaborate with other departments on clinical and non-clinical performance improvement projects.
- Research best practices, national and regional benchmarks, and industry standards.
- Develop collaborative relationships with contracted providers and provider groups to encourage participation in quality improvement collaboratives.
- Lead or participate in external activities, work groups, or committees when applicable.
- Communicate programs, interventions, and results to external entities in accordance with applicable objectives, policies, and procedures.
- Develop or maintain relationships with external organizations to expand key partnerships.
- Assess industry trends and regulations for enterprise-wide adoption to support quality and effective health care delivery and services.
- Perform other duties as assigned and comply with all policies and standards.
Benefits
- Competitive pay
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work, with remote, hybrid, field, or office work schedules
- Additional forms of incentives may be included in total compensation, subject to program eligibility
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What This Job Offers
Job Type
Full-time
Career Level
Senior
