Quality Improvement Specialist

Job Description

Job Description

Position Summary :

Utilizes knowledge of nursing and preventative health practices through performance of medical chart audit / abstraction and analysis of quality related data as defined through Health Effectiveness Data Information Set (HEDIS) outcome reporting. Participates in quality improvement initiatives to ensure health plan quality goals are achieved. Works closely with providers, enrollees, and health plan staff to ensure the highest standard of quality care is provided to health plan enrollees using the process improvement process (PDSA) by performing the following duties.

Essential Duties and Responsibilities :

• Collaborates with provider offices and management staff to propose innovative techniques for improving enrollee care delivery and close gaps in care.
• Audit medical records, review administrative claims, and analyze data and interventions for quality improvement studies and activities.
• Promote process improvement based on performance measure and quality audit results.
• Conduct analysis for priority workflows based on performance measure gaps.
• Collaborate with other health plan departments to improve performance measure scores.
• Work with subject matter experts to support accreditation, regulatory, and quality management program activities.
• Coordinate special projects that enhance the overall success of the quality program.
• Evaluate performance measure scores to identify potential improvements.
• Provides support for quality improvement initiatives utilizing clinical knowledge and expertise.
• Engage in quality committees focused on improving care and service outcomes.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications :

Skills and Abilities :

Work Schedule :

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and / or move up to 15 pounds.

Work Environment :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside / outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.