Market Clinical Quality Specialist II

Job Summary

The Market Clinical Quality Specialist II completes assigned case/file reviews to ensure adherence to regulatory requirements and identified Standard Operations Procedures (SOPs)..

Essential Functions

• Ensure compliance with adherence to regulatory requirements and identified Standard Operating Procedures (SOPs) through monthly inter-rater reliability monitoring of case reviews
• Identify departmental training and development opportunities and work collaboratively with peers and Care Management to develop the needed education and/or training
• Assist Management with reporting of case reviews that can be communicated at overall aggregate and individual contributor levels
• Subject matter expert (SME) in assigned area(s)
• Participate in interdepartmental meetings/workgroups, as directed, to ensure that new operational procedures and updates to existing procedures for Care Management (CM) are compliant with contract requirements
• Provide cross-functional assistance to meet monitoring, accreditation and operational responsibilities to ensure adherence to regulatory requirements
• Maintain familiarity with all applicable Federal and State Requirements, which include the Corporate Integrity Agreement responsibilities; also responsible for monitoring changes within those requirements, identifying the areas that will be impacted, communicating the changes and assisting with implementation of the changes
• Continuously pursue and identify best practices as well as opportunities for improvement and facilitate implementation of improvement initiatives for health services monitoring and accreditation
• Perform any other job related instructions as requested

Education and Experience

• Associate of Science in Nursing (ASN) is required
• Bachelor of Science in Nursing (BSN) is preferred
• One to three (1 to 3) years of experience in Quality Improvement, Project Management, Case Management or Utilization Review is required
• Minimum of three (3) years of diverse clinical experience as an RN is preferred

Competencies, Knowledge and Skills

• Intermediate in Microsoft Excel, Access and Word
• Intermediate skill level with SharePoint
• PowerPoint and Visio preferred
• Strong written and verbal communication skills Ability to work independently and within a team environment
• Familiarity of the healthcare field
• Knowledge of Medicaid and Medicare
• Effective listening and critical thinking skills
• Strong interpersonal skills and high level of professionalism
• Effective problem solving skills with attention to detail
• Ability to develop, prioritize and accomplish goals
• Technical writing skills
• Ability to coordinate complex projects and multiple meetings
• Ability to work with a variety of disciplines and levels of staff across departments

Licensure and Certification

• Current, unrestricted Registered Nurse (RN) licensure in state of practice, is required
• Case Management Certification, such as Certified Case Manager (CCM) through the Commission for Case Management Certification (CCMC), is highly preferred

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time