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Quality Improvement Specialist at WellCare Health Plans

Posted in Engineering 30+ days ago.

This job brought to you by Professional Diversity Network, Inc

Type: Full Time
Location: Omaha, Nebraska

Job Description:

Supports the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies impacting plan compliance to regulatory and accreditation standards. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytic and reporting activities.
Reports to: Mgr, Quality Improvement
Department: NE-Health Services QI-State
Position Location: Omaha, NE
Essential Functions:
Monitors quality improvement initiatives including, but not limited to, development and implementation of preventive health and chronic disease outcome improvement interventions such as: newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys.
Monitors and investigates all quality of care and collaborates with medical directors to determine impacts and next steps for actions. Monitors provider quality complaints to identify trends and educational opportunities for improvement.
Analyzes, updates, and modifies procedures and processes to continually improve QI operations.
Collects and summarizes performance data and identifies opportunities for improvement.
Serves as knowledge expert for continuous quality improvement activities, QIPS, PIPs and QIAs.
Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met.
Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA,EQRO).
Conducts internal auditing of compliance with regulatory and accreditation standards.
Supports the implementation of the quality reporting infrastructure.
Pursues methods to ensure receipt of data required for trending and reporting of various QI work plan metrics, performs adequate data/barrier analysis, develops improvement recommendations, and deploys actions as approved.
Assists in activities to prioritize clinical and service improvement initiatives.
Participates in various QI committees and work groups convened to improve process and/or health outcomes, and contributes meaningful detail, based on functional knowledge. Completes follow-up as assigned.
Manages and monitors assigned quality studies.
Investigates and incorporates national best practice interventions to affect greater rate increases.
Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
Performs other duties as assigned. Additional Responsibilities:
Completes Licensed Health Care Risk Management certification program.
Performs annual update on Plan Risk Management Program Description.
Coordinates the regular and systematic review of all potential adverse incidents in accordance with state statute.
Completes AHCA Code 15 Reports for confirmed adverse incidents.
Submits an annual AHCA adverse incident summary report.
Presents summary reports of reported AHCA Code 15 adverse incidents through the quality committee structure and Board of Directors.
Candidate Education:
Required A High School or GED with a current unrestricted RN license
Preferred A Bachelor's Degree in Healthcare, Nursing, Health Administration, Public Health or related health field Candidate Experience:
Required 2 years of experience in Quality Improvement
Required 3 years of experience in Managed Care
Required Other Experience in compliance and accreditation
Required Other Knowledge of federal and state regulations/requirements Candidate Skills:
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Ability to multi-task
Intermediate Ability to work in a fast paced environment with changing priorities
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Advanced Ability to create, review and interpret treatment plans
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate Knowledge of healthcare delivery
Intermediate Knowledge of community, state and federal laws and resources
Intermediate Demonstrated time management and priority setting skills
Intermediate Ability to implement process improvements Licenses and Certifications:
Required Technical Skills:
Required Intermediate Microsoft Excel
Required Intermediate Healthcare Management Systems (Generic)
Required Intermediate Microsoft Word
Required Intermediate Microsoft Outlook Languages:
About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.