Quality Provider Oversight Lead, HYBRID

Health Services for Children with Special Needs•Washington, WA

13d•Hybrid

About The Position

The Quality Provider Oversight Lead is responsible for the integrity, assurance, and improvement of the services delivered to HSCSN enrollees. This role will work closely with HSCSN Quality Assurance leadership, HSCSN various departments, Children's National partners, and HSCSN providers/practitioners and stakeholders as an enrollee advocate and quality provider liaison. This role will develop and improve processes, address ongoing/potential areas of quality deficiencies or risks, and ensure high value of care delivery for enrollees.

Requirements

Bachelor's Degree in nursing (BSN) (Required)
3-5 years of experience in the area of quality and health outcomes, home health agency oversight, provider site audits, provider engagement and education.
Registered Nurse
Knowledge of: Centers for Medicare & Medicaid Conditions of Participation for home health agencies, the DC regulations for home care agencies, and scope of practice for various provider types (RNs, LPNs, PCAs, etc).
Quality improvement and general quality concepts (I.e. if no formal training, would be asked to complete IHI Basic Certificate within 90 days of start)
Available home care services and provider types
Nursing assessment, diagnosis, planning, intervention, and evaluation process
The healthcare environment as it relates to the care delivery systems
NCQA standards and expectations including compliance requirements
Age-specific care
Culturally sensitive care

Responsibilities

Developing and maintaining provider engagement, oversight and education using quality oversight processes
Proactively identify enrollee needs across the HSCSN provider network through the lens of quality monitoring, oversight, provider education, connection to care, delivery of services, and transition out of care in partnership with multiple teams (both internal and external to HSCSN) and stakeholders involved in these processes.
Ensure high quality provider engagement & collaboration through comprehensive training , quality site visits and audits .
Conduct ongoing quality site visits, provider education, trainings and engagement activities to support care gap closure and QI initiatives
Collaborate with Compliance, Medical Affairs and Appeals and Grievances during complaints or potential quality issue (PQI) investigations including provider site visits, development and monitoring of corrective action plans.
Audit home health agencies through site visits and point of care home visits.
Lead Home health agency trainings /forums in collaboration with other HSCSN departments at least twice a year.
Ensure Home health agenc y oversight, training and monitoring of corrective action plans and receive individual and small group refresher training sessions and resource support.
Convene quarterly Home Health Agency sub-committee in collaboration with HSCSN internal stakeholders (Medical Affairs, Provider Relations, Compliance, Quality)
Ensure HSCSN provider focused quality engagement activities and home health oversight process and outcomes are included in the Quality Assessment and Performance Improvement (QAPI) Program, workplan, and evaluation.
Participate in the Mortality Review Workgroup to review mortality events for prevention and improvement opportunities as well as measuring process measures related to contractual compliance with notification of mortality events.
Schedule and coordinate internal monitoring/audits
Conduct site visits of every home health agency in the HSCSN Provider Network at minimum annually, but more frequently when required by regulator, leadership, or required by corrective action plan.
Conduct unannounced site visits on a routine basis to evaluate quality of clinical care and ensure compliance with contractural standards.
Ensure that only home health agencies with a pediatric certificate of need (CON), administered by DOH, provide home health services to children and adolescents.
Submit to DHCF annually, for review and approval, all on site monitoring and evaluation tools utilized for home health agencies by the Quality .
Submit any proposed revisions to monitoring and evaluation tools to DHCF for prior approval before use.
Participate as home care lead in external audits (I.e. OSR) or accrediting efforts (I.e NCQA) to make sure HSCSN’s policies and procedures are meetings standards and striving for excellence.
May perform other duties in addition to those outlined in this job description.