Manager, Clinical Quality Improvement

Caresource Atlanta , GA 30301

Posted 1 week ago

Role and Responsibility:

  • Oversee the ongoing clinical management of Patient Centered Medical Home (PCMH) initiatives, clinical practice guideline initiatives and clinical performance improvement initiatives

  • Manage a team of provider-facing, clinical Quality Improvement staff; directs activities, hires, trains, coaches, counsels, and evaluates performance of direct reports

  • Assist with developing annual HEDIS and CAHPS project plans; monitor project progress and timeliness to ensure deadlines are met

  • Build and manage relationships with external vendors and physician practices

  • Attend quality-related provider meetings

  • Serve as the trainer of PCMH to staff and lead multi-disciplined practice transformation and practice performance improvement initiatives and guide practices in achieving targeted goals that include quality, efficiency and utilization

  • Accountable for successful deployment of the PCMH program at the practice level, including but not limited to, introducing, educating and supporting practices on PCMH transformation

  • Design practice transformation action plans and implement appropriate performance improvement initiatives designed to assist the practice in achieving contractually required transformation milestones

  • Use data to analyze trends and work with providers to implement proactive strategies to address issues and measure impact using a PDSA rapid cycle improvement approach

  • Work with practices to align and integrate care management programs and population health services to augment the practice capabilities, support their care management efforts and add value to the patient care experience

  • Ensure compliance with HEDIS specifications, policies, operating procedures, and goals in compliance with internal and external guidelines

  • Serve as the liaison and work closely with the Enterprise Manager of HEDIS Operations and the Georgia market

  • Serve as the Subject Matter Expert of HEDIS and other performance measure Technical Specifications

  • Identify and close data collection gaps and opportunities to increase performance outcomes

  • Consult and guide the practice on developing innovative solutions, including bringing best practice experience and connecting

  • Develop and execute clinical quality programs and initiatives to improve member health outcomes and drive quality metric goal attainment

  • Review, track and trend QI and grievance issues for all programs in addition to prep work for Quality Oversight Committee (QOC)

  • Maintain reports for QI trends and metrics, as well as prepare reports for Delegation Oversight

  • Prepare reports for state and federal requirements

  • Ensure all clinical quality issues are resolved within specified timeframes as indicated by the states served and programs therein, CMS and all accrediting entities

  • Perform reviews, tracking and trending of Potential Member Risk (PMR) cases, referring appropriate cases to Fraud & Abuse and preparing reports for presentation to senior management

  • Review and maintain compliance of Quality Improvement policies with NCQA standards

  • Maintain case files for all Quality of Care (QOC) issues and maintain database of QOC cases

  • Request medical records, review documentation and assign a severity level to each Quality of Care case or forward to appropriate medical/dental/specialty reviewer

  • Act as liaison between the QI program and the Care Management and Behavioral Health programs

  • Develop materials and provide education on the reporting of Quality of Care Grievances and Sentinel Events to other appropriate departments within CareSource

  • Review QOC cases, as needed, with the Georgia Market Medical Director and carry out actions as indicated by the Medical Director

  • Maintain accurate individual Excel spreadsheet, showing the status of each open QOC case

  • Track and monitor provider QI issues for monthly reporting of provider re-credentialing to Network Operations

  • Perform External Quality Review (EQR) record retrieval, research record and review

  • Perform any other job related duties, as requested


Education / Experience:

  • Associate of Science in Nursing is required

  • Bachelor of Science Degree in Nursing (BSN) is preferred

  • Minimum of three (3) years clinical experience as an RN is required

  • Managing clinical staff of RNs for a minimum of 2 years is required

  • Managed Care experience is preferred

  • HEDIS and NCQA experience is preferred

  • Physician practice experience is preferred

  • Project management experience is preferred

Required Competencies / Knowledge /

  • Proficiency in Microsoft Excel, Access and Word

  • Advanced knowledge of PCMH and HEDIS

  • Knowledge of NCQA standards

  • Familiarity with SharePoint preferred

  • Demonstrated ability in implementing Clinical Practice Transformation initiatives designed to help provider or hospital groups achieve health transformation goals is preferred

  • Strong relationship building skills with internal and practice teams to drive goal alignment

  • Strong written and verbal communication skills

  • Strong presentation skills to all levels of organization

  • Ability to work independently and within a team environment

  • Familiarity of the healthcare field

  • Knowledge of Medicaid

  • Effective listening and critical thinking skills

  • Strong interpersonal skills and high level of professionalism

  • Effective problem solving skills with attention to detail

  • Ability to develop, prioritize and accomplish goals

  • Customer service oriented

  • Analytical and organizational skills

  • Exceptional analytical, problem solving and critical thinking skills

  • Demonstrated ability in identifying problems, developing solutions and implementing effective courses of action

  • Strong communication skills required, including the abilities to effectively communicate verbally and in writing, internally and externally, and at different levels as necessary

  • Demonstrated ability to work effectively and productively with varied levels of personnel, with professionals and business organizations

  • Strong service orientation and consulting skills

  • Ability to lead mission-critical, high visibility projects

  • Proven ability to juggle multiple complex priorities within a changing environment

  • Excellent writing skills

Licensure / Certification:

  • Current, unrestricted license in the state of Georgia as a Registered Nurse (RN) is required

Working Conditions:

  • General office environment; may be required to sit/stand for long periods of time

  • Must be willing to travel up to 50% of time to fulfill work duties

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Manager, Clinical Quality Improvement