Oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities.
The Senior Specialist, Quality Improvement (Registered Nurse) contributes to one or more of these quality improvement functions: Quality Interventions, Quality Improvement Compliance, HEDIS, and / or Quality Reporting.
Quality Intervention / QI Compliance
• Acts as a lead specialist to provide project-, program-, and / or initiative-related direction and guidance for other specialists within the department and/or collaboratively with other departments.
• Implements key quality strategies that require a component of near real-time clinical decision-making. These activities may include initiation and management of interventions (e.g., removing barriers to care); preparation for Quality Improvement Compliance surveys; preparation and review of potential quality of care and critical incident cases; review of medical record documentation for credentialing and model of care oversight; and any other federal and state required quality activities.
• Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately in order to present results to key departmental management and other departments as needed.
• Writes narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions.
• Creates, manages, and/or compiles the required documentation to maintain critical quality improvement functions that have a component of clinical decision-making.
• Leads quality improvement activities, meetings and discussions with and between other departments within the organization. Often the Senior Specialist will be assigned activities where clinical expertise is important to the activity.
Bachelor's degree in nursing or higher
• Min. 3 years experience in healthcare with minimum 2 years experience in health plan quality improvement, managed care or equivalent experience.
Required License, Certification, Association
Active RN license for the State(s) of employment
Preferred field: Clinical Quality, Public Health or Healthcare. Nursing: Master's or higher
• 2 years coding and medical record abstraction experience.
• 1 year managed care experience.
• Basic knowledge of HEDIS and NCQA.
Preferred License, Certification, Association
• Certified Professional in Health Quality (CPHQ)
• Certified HEDIS Compliance Auditor (CHCA)
• Registered Health Information Technician (RHIT), or
• Certified Medical Record Technician with training in coding procedures (as required by state/location only), or
• Certified Professional Coder (CPC)
Registered Health Information Technician
Certified Professional Coder
Healthcare Effectiveness Data And Information Set