Quality Perform Spec Clinical

Amerihealth Caritas • Raleigh, NC

4d • 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. 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. Strong maternal and / or women's health background strongly preferred.

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 or equivalent work experience.
• Minimum of 3 years in clinical or service quality improvement/ health care delivery or relevant experience required.
• An unrestricted Clinical license (RN) in the plan’s state or any other state he/she works required.
• Proficient with Microsoft Office applications including Word, PowerPoint, Excel 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/management preferred.
• Knowledge and understanding of QI functions in an MCO preferred.
• Knowledge of Medicaid and Medicare preferred.

Responsibilities

• 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.
• Supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines.
• Supports accreditation and clinical quality performance improvement activities.
• Assumes responsibility for performing quality of care reviews to include all sentinel events and member concerns.
• Coordinates reviews with physician advisors and clinical quality committees as appropriate.
• Assures minimally necessary medical records are collected and organized for clinical review to occur.
• Summarizes all clinical findings for review by clinical committees as appropriate.
• Assist with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets, schedules, agendas, and the review and approval of minutes.
• Reviews and approves the QM work plan on an annual basis including selection of performance measures, goals, objectives, and thresholds.
• Review and suggest new and/or improved QM activities using Plan-Do-Study-Act Cycles.
• Develops QOC quarterly trending reports for QAPI for input and direction.
• Follows up on any recommendations.
• Adheres to QM policies including annual reviews, updates, and approvals.
• Participates and assist in activities and reporting to maintain compliance with state regulations and NCQA standards for quality activities.
• Supports 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.
• Assistance will be based upon the organizations needs annually but may include participation in the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.
• All other duties as assigned.

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