[Hiring] Quality Performance Specialist Clinical @Amerihealth Caritas

Role Description

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. Responsibilities include:

• 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.
• 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 QM 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 and 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.
• Assisting in the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.
• Performing all other duties as assigned.

Qualifications

• Associate’s Degree or equivalent work experience; Bachelor’s Degree preferred.
• 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.
• Prior experience with project facilitation/management preferred.
• Knowledge and understanding of QI functions in an MCO preferred.
• Knowledge of Medicaid and Medicare preferred.
• Proficient with Microsoft Office applications including Word, PowerPoint, Excel required.

Requirements

• Remote based position with a strong preference for a North Carolina resident.
• 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.

Benefits

• Flexible work solutions including remote options and 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) plan.
• Tuition reimbursement and more.