Job Profile Summary
Position Purpose: Analyze, develop, implement and monitor clinical quality improvement initiatives to achieve healthy outcomes.
Education/Experience: Bachelor s degree in nursing preferred. 2+ years clinical, quality management or healthcare related experience. At least one year experience in quality function in a healthcare setting.
License/Certification: LPN, LVN, RN, PA, or LCSW license preferred. Utilization management certification preferred. Certified Professional in Healthcare Quality preferred.
Responsibilities
Perform duties and functions to comply with quality improvement programs according to state requirements.
Support Quality Assurance Performance Improvement work plan/initiatives.
Schedule and assist with committee and sub-committee preparation.
Assist in investigation and resolution of member quality of care complaints.
Audit medical records and monitor performance measures for health care risk management, sentinel events and trends.
For PA H&W only:
Responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department s EQR contractor."
EEO:
Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.
Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits. Perform community activities related to clinical initiatives such as health fairs and communication with agencies and providers. Collaborative culture. Key project to complete AHCCCS Medicaid QOC investigations.
Systems Word, teams, outlook, power point, excel, one drive, one note & specialized report system
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| Typical Day in the Role |
Receive 1-3 QOC investigations daily that are due 60 days from the assignment date. Reviewing medical records, provider policies/manuals and statutes to ensure providers are rendering appropriate care to our members per the guidelines. Writing an investigative report of findings and submitting reports.
Expectation to complete 1 investigative report per day. The role is unique as it requires clinical knowledge to be able to identify quality concerns and develop quality improvement plan to address the concerns with the provider. | |