Quality Performance Specialist Clinical

Responsibilities

As part of the Quality Management team, the Quality Performance Specialist Clinical is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing standards of care for AmeriHealth Caritas Pennsylvania . In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines. The position also supports accreditation and clinical quality performance improvement activities.

• Assumes responsibility for performing quality of care reviews to include all sentinel events and member concerns. Coordinates reviews with physician advisors and clinical quality committees as appropriate.
• Assures minimally necessary medical records are collected and organized for clinical review to occur. Summarizes all clinical findings for review by clinical committees as appropriate.
• Assist with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets, schedules, agendas, and the review and approval of minutes.
• Reviews and approves the quality management work plan on an annual basis including selection of performance measures, goals, objectives, and thresholds
• Review and suggest new and/or improved QM activities using Plan-Do-Study-Act Cycles
• Develops QOC quarterly trending reports for QAPI for input and direction. Follows up on any recommendations.
• Adheres to QM policies including annual reviews, updates, and approvals.
• Participates and assist in activities and reporting to maintain compliance with state regulations and NCQA standards for quality activities
• Supports the quality improvement department with annual medical record review activities including HEDIS, NCQA and Clinical Practice Guidelines by working collaboratively with the Quality

Education/Experience

• Associate’s Degree in Nursing required; Bachelor’s Degree preferred
• Minimum of 3 years in clinical or service quality improvement, healthcare delivery or a related field
• Experience with medical record review
• Prior experience with project facilitation or project management preferred.
• Knowledge of Medicaid programs preferred.

Licensure

• An active and unencumbered Registered Nurse license required

Skills and Abilities

• Strong knowledge of clinical quality standards, regulatory requirements, and accreditation processes (e.g. NCQA and HEDIS)
• Ability to analyze medical records and identify quality-of-care trends and gaps
• Effective collaboration skills with clinicians, physician advisors, and cross functional teams
• Strong organizational skills with the ability to manage multiple priorities and deadlines
• Clear and concise written and verbal communication skills, including report development
• Detail-oriented with the ability to synthesize complex clinical information into actionable items
• Proficiency in data tracking, reporting and using Microsoft Office tools (Word, PowerPoint, Excel, Teams) required

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.