About the Role

• This position is responsible for developing, organizing, collecting, coordinating, preparing, and presenting results of quality improvement studies and project activities.
• The goal is to monitor, evaluate, and continuously improve the quality of healthcare services provided to members.

Responsibilities

• Collaborate with the Quality Improvement department staff to develop quality improvement studies, initiatives, and projects aimed at enhancing member healthcare.
• Plan and coordinate the collection, evaluation, and dissemination of quality improvement data to comply with regulatory requirements and accreditation standards.
• Prepare reports and analyses to evaluate performance against standards from various sources, including materials, documents, medical charts, provider offices, and facilities.
• Conduct qualitative and quantitative analysis to identify significant clinical issues, develop improvement plans, and measure the impact of actions.
• Participate in accreditation and regulatory audit preparedness, maintaining activities such as preparing reports, narratives, graphs, and charts for external audits and surveys.
• Facilitate quality improvement program committees, including preparing materials, minutes, and tracking action items for committee review.
• Develop and maintain Quality Improvement department policies, procedures, materials, and reports in accordance with State, Federal, and accreditation requirements.
• Perform audits of materials and medical records to demonstrate compliance with contractual obligations, identify improvement opportunities, and validate medical record-keeping practices for credentialing and recredentialing.
• Collect HEDIS data and/or Medical Record Review Data through chart review of medical records as directed.
• Support various HEDIS activities as needed. 
• Review, identify, and trend quality of care issues, serious reportable adverse conditions, and assist in implementing corrective action plans. 
• Participate in developing materials for member and provider quality initiatives such as HEDIS, improvement projects, and studies.

Education Qualification

• No specific educational qualifications are required, but a background in healthcare or a related field is preferred.

Required Skills

• Proficiency with PC-based systems.
• Excellent verbal and written communication skills.
• Ability to 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. 
• 0-2 years of experience in Quality Improvement.
• 0-2 years of experience in the managed care or healthcare industry.
• Experience with qualitative or quantitative projects/analysis.
• Licensure/Certification None required. RN/LPN preferred.