QI Specialist I

Job Description:

100% REMOTE BUT MUST RESIDE IN Texas

POSITION OPENING IS DUE TO RADV AUDIT REQUIREMENT FOR HEALTHPLAN

ROLE IS FOR A PROVIDER ENGAGEMENT SPECIALIST

MUST WORK 8AM TO 5PM MDT MONDAY TO FRIDAY



Job Description:

Summary: Responsible for developing, organizing, collecting, coordinating, preparing and presenting results of quality improvement studies and projects activities to monitor, evaluate and continuously improve the quality of healthcare services provided to Client member.



Essential Functions:

Collaborates with the Quality Improvement department staff in the development of quality improvement studies, initiatives and projects to improve the health care of members.

Plans and coordinates the collection, evaluation and dissemination of quality improvement data for quality initiatives, studies and projects to comply with regulatory requirements and accreditation standards.

Prepares reports and analyses to evaluate performance with standards from a variety of sources such as and not limited to: materials, documents, medical charts, provider offices, and/or facilities.

Performs with qualitative and quantitative analysis to identify significant and problematic clinical issues and concerns, development of improvement plans and measurement to assess impact of actions.

Participates in NCQA accreditation and regulatory audit preparedness and maintains activities including preparing reports, narratives, graphs, charts, etc. as needed for external audits and surveys.

Participates in and facilitates quality improvement program committees, as assigned, including preparing materials, minutes and tracking action items for committee review.

Develops and maintains Quality Improvement department policies and procedures, materials and reports in accordance with State, Federal, and NCQA and Client requirements. State Plan / Department Specific Duties and Responsibilities

Performs audits of materials and medical records to demonstrate compliance with contractual obligations, identify opportunities for improvement, and to validate medical record-keeping practices for credentialing and recredentialing purposes.

Collects HEDIS data and/or Ambulatory Medical Record Review Data through chart review of medical records (medical record abstraction) as directed.

Supports various HEDIS activities as needed.

Reviews, identifies and trends quality of care issues, serious reportable adverse conditions and assists in the implementation of corrective action plans.

Participates in the development of materials as needed for member and provider quality initiatives such as HEDIS, improvement projects, and studies.



Knowledge/Skills/Abilities:

Proficiency with PC-based systems

Excellent verbal and written communication skills

Ability to abide by Client s policies

Ability to maintain attendance to support required quality and quantity of work

Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)

Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers



Required Experience:

0-2 years experience in Quality Improvement.

0-2 years experience in managed care or healthcare industry.

Experience with qualitative or quantitative projects/analysis.



Required Licensure/Certification: None required. RN/LPN preferred



Must Have Skills:

Knowledge/Skills/Abilities:

Proficiency with PC-based systems

Excellent verbal and written communication skills

Ability to abide by Client s policies

Ability to maintain attendance to support required quality and quantity of work

Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)

Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers



Day to Day Responsibilities: Day to Day Responsibilities:

Contact providers to collect required medical records for RADV audit. May need to go to the clinic location to collect medical records.

Work collaboratively with other Client departments to secure medical records for audits.

Collaborates with the Quality Improvement department staff in the development of quality improvement studies, initiatives and projects to improve the health care of members.

Plans and coordinates the collection, evaluation and dissemination of quality improvement data for quality initiatives, studies and projects to comply with regulatory requirements and accreditation standards.

Prepares reports and analyses to evaluate performance with standards from a variety of sources such as and not limited to: materials, documents, medical charts, provider offices, and/or facilities.

Performs with qualitative and quantitative analysis to identify significant and problematic clinical issues and concerns, development of improvement plans and measurement to assess impact of actions.

Participates in NCQA accreditation and regulatory audit preparedness and maintains activities including preparing reports, narratives, graphs, charts, etc. as needed for external audits and surveys.

Participates in and facilitates quality improvement program committees, as assigned, including preparing materials, minutes and tracking action items for committee review.

Develops and maintains Quality Improvement department policies and procedures, materials and reports in accordance with State, Federal, and NCQA and Client requirements. State Plan / Department Specific Duties and Responsibilities

Performs audits of materials and medical records to demonstrate compliance with contractual obligations, identify opportunities for improvement, and to validate medical record-keeping practices for credentialing and recredentialing purposes.

Collects HEDIS data and/or Ambulatory Medical Record Review Data through chart review of medical records (medical record abstraction) as directed.

Supports various HEDIS activities as needed.

Reviews, identifies and trends quality of care issues, serious reportable adverse conditions and assists in the implementation of corrective action plans.

Participates in the development of materials as needed for member and provider quality initiatives such as HEDIS, improvement projects, and studies.



Required Years of Experience:

0-2 years experience in Quality Improvement.

0-2 years experience in managed care or healthcare industry.

Experience with qualitative or quantitative projects/analysis.