Quality Perform Spec Clinical

Amerihealth Caritas • Raleigh, NC

20h • Remote

About The Position

As part of the Quality Management team, the Quality Performance Specialist Clinical is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing standards of care for AmeriHealth Caritas North Carolina. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines. The position also supports accreditation and clinical quality performance improvement activities.

AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Requirements

• Associate’s Degree in Nursing required
• Minimum of 3 years in clinical or service quality improvement, healthcare delivery or a related field
• An active and unencumbered Registered Nurse license required
• Strong knowledge of clinical quality standards, regulatory requirements, and accreditation processes (e.g. NCQA)
• Ability to analyze medical records and identify quality-of-care trends and gaps
• Effective collaboration skills with clinicians, physician advisors, and cross functional teams
• Strong organizational skills with the ability to manage multiple priorities and deadlines
• Clear and concise written and verbal communication skills, including report development
• Detail-oriented with the ability to synthesize complex clinical information into actionable items
• Proficiency in data tracking, reporting and using Microsoft Office tools (Word, PowerPoint, Excel, Teams) required
• Must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required.

Nice To Haves

• Bachelor’s Degree preferred
• Strong maternal and / or women's health background strongly preferred
• Prior experience with project facilitation or project management preferred
• Knowledge and understanding of quality improvement functions within an managed care organization preferred
• Knowledge of Medicaid and Medicare programs preferred
• Experience with quality improvement methodologies such as Plan-Do-Study-Act (PDSA)

Responsibilities

• Leading and coordinating the clinical quality review process of member concerns and medical records utilizing standards of care for AmeriHealth Caritas North Carolina.
• Supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines.
• Supporting accreditation and clinical quality performance improvement activities.
• Performing quality of care reviews to include all sentinel events and member concerns.
• Coordinating reviews with physician advisors and clinical quality committees as appropriate.
• Assuring minimally necessary medical records are collected and organized for clinical review to occur.
• Summarizing all clinical findings for review by clinical committees as appropriate.
• Assisting with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets, schedules, agendas, and the review and approval of minutes.
• Reviewing and approving the quality management work plan on an annual basis including selection of performance measures, goals, objectives, and thresholds.
• Reviewing and suggesting new and/or improved QM activities using Plan-Do-Study-Act Cycles.
• Developing QOC quarterly trending reports for QAPI for input and direction.
• Following up on any recommendations.
• Adhering to QM policies including annual reviews, updates, and approvals.
• Participating and assisting in activities and reporting to maintain compliance with state regulations and NCQA standards for quality activities.
• Supporting the quality improvement department with annual medical record review activities including HEDIS, NCQA and Clinical Practice Guidelines by working collaboratively with the Quality Improvement Department.
• Assisting with the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.

Benefits

• Flexible work solutions including remote options, hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement
• Reimbursement for internet service for fully remote associates residing in states where service is required by contract, law, or regulation.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree