Quality Improvement Specialist Sr

HEDIS Operations experience highly preferred
Clinical Medical Record Review experience.

Position Purpose: The Senior Quality Improvement Specialist is responsible for coordinating assigned regulatory, accreditation, clinical quality and/or service improvement programs. Functions as a leader for assigned health services initiatives handling multiple large-scale complex initiatives. Collaborates on national, regional and multi-plan initiatives. Develops programs in compliance with accreditation and regulatory requirements/ standards and monitors ongoing program performance to maintain compliance. Acts as a resource for training, policy and regulatory/accreditation interpretation.
- Leads and manages multiple complex initiatives that impact the quality or effectiveness of health care delivery and/or health care services provided to members.

- Ensures that clinical and service quality improvement programs and initiatives are compliant with applicable accreditation, state and federal requirements.

- Conducts an assessment of programs, initiatives and interventions to ensure goals and objectives were met and refine activities, as needed, to improve the effectiveness and improve outcomes.

- Conducts vendor oversight and management.

- Develops targeted activities to improve Star Ratings, HEDIS, CAHPS, HOS, provider satisfaction and other identified performance measures.

- Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas.

- Participates in the development and maintenance of annual quality improvement program documents and evaluations, compliance audits, policies and procedures, and improvement activities.

- Develops internal reports to demonstrate progress on each initiative/project and presents to senior-level staff.

- Describes outreach initiatives, potential/experienced barriers and activities to resolve issues and improve outcomes.

- Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management.

- Identifies areas of improvement within the company and works collaboratively with other departments to develop clinical and non-clinical performance improvement projects.

- Researches best practices, national and regional benchmarks, and industry standards.

- Develops collaborative relationships with contracted providers or provider groups to promote participation in quality improvement collaboratives to improve clinical care outcomes.

- May lead and/or participate in external activities, work groups or committees when applicable.

- Communicates programs, interventions and results to external entities in accordance with applicable program objectives, policies and procedures.

- Develops and/or maintains relationships with other external organizations to expand key partnerships.

- Assesses current industry trends and regulations for enterprise-wide adoption to assure quality and effectiveness of health care delivery and/or healthcare services provided to members.

- Performs all other duties as assigned.

- Performs other duties as assigned

- Complies with all policies and standards

Education/Experience:
Education: Bachelor’s Degree or equivalent experience with clinical license or Master’s Degree in related health field (i.e. MPH or MPA)

Certification/License: Valid state clinical license preferred
Certified Professional in Health Care Quality (CPHQ) preferred.

Experience: Minimum three years experience in a clinical/health care environment with related degree program
Three to five years managed care experience in a health care environment
Experience in compliance, accreditation, service or quality improvement

Complex project management experience

Experience with Medicare and/or NCQA preferr