Quality Management Specialist - RN at Independence Blue Cross LLC in Philadelphia, Pennsylvania

Job Description:

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.

Job Summary Quality Specialist RN

Reporting to the Manager of Quality Management. The QM Specialist- RN responsibilities include addressing regulatory and accreditation requirements, analyzing and developing reports, developing interventions, coordinating committee meetings, participating on various committees, annual policy reviews, screening, analyzing and investigating occurrences and quality of care complaints and tracking and updating QM work plan activities.

Responsibilities

·       Maintain all NCQA Accreditation statuses for PA and NJ health plans and AHA 

·       Monitor the overarching NCQA Work Plan and oversee QM team leads with assigned NCQA Standards.

• Collaborate with operational depts. in developing an action plan to close identified gaps.

·       Review current occurrence and quality of care complaint processes and complete ongoing investigations of occurrences and quality of care complaints.

·       Review ongoing medical and behavioral treatment to ensure treatment is consistent with standards of care

·       Coordinate aspects of the monthly Quality Meetings as necessary  

·       Complete assigned QM documents with accuracy and within the required timeframes.

Qualifications

Education

Registered Nurse (RN) licensed to practice.

Experience, Knowledge, & Skills

·       Minimum of five (5) years of progressive responsibility required in a managed care setting.

·       Preferred three (3) years of behavioral health, and/or drug and alcohol work experience.

·       Familiarity of regulatory and accreditation requirements required.

·       Excellent organizational, interpersonal, analytical, presentation and written skills required.

·       Demonstrated ability to interact effectively with all levels of staff.

·       Excellent interpersonal, verbal and written communication skills.

·       Must have an organized work manner inclusive of time management and the ability to prioritize workflow.

·       Proven ability to work independently, maintain flexibility, and work as part of the departmental team

·       Leads and /or facilitates clinical performance improvement teams/taskforce as indicated.

·       Serves as a team facilitator and consultative resource for clinical and departmental leadership and staff

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