Quality Performance Specialist must be an RN per contract. Can be based from North Caroline home but must be able to travel throughout region.
Your career starts now. We’re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, 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. Discover more about us at [ Link removed ] - Click here to apply to Quality Performance Specialist Clinical RN.
This position is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing of care standards. 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.
Assumes responsibility for reviewing all sentinel events and member concerns reported for potential quality of care issues.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.
Prepares meeting packets, schedules meetings, develops agendas, completes minutes, and chairs the Internal Quality Review Committee (IQRC).
Maintains database to support trending and reporting of adverse outcomes resulting from clinical care provided.
Develops reports and analysis for semi-annual trending reports and presents to the Quality Medical Management Committee (QMMC) for input and direction.Follows up on any recommendations.
Maintains QR policies including annual reviews, updates, and approvals.
Maintains hard copy documentation in accordance with contractual requirements.
Conducts analysis annually on the Plan’s efforts to improve the safety of members.
Supports the quality improvement department with annual medical record review activities including HEDIS, 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.
Performs other related duties and special projects as assigned.
Key Competencies/Success Factors:
Excellent written and verbal communication skills
Ability to positively interact and work collaboratively with varying levels of education and background
Ability to organize multiple projects while adhering to objectives and timelines
Ability to function independently with little or no supervision
Ability to incorporate Mission and Values into job performance and duties
Experience and Education:
3-5 years quality improvement experience required
2-4 years experience in project facilitation/management role
Knowledge of Medicaid and Medicare preferred
Knowledge and understanding of QI functions in an MCO preferred
Proficient with Microsoft Office applications including Word, PowerPoint, Excel required
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