Quality Mgmt Spec I

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This position is responsible for facilitating all aspects of assigned clinical quality improvement projects and evaluation of PCP/MG/IPA compliance with clinical practice guidelines; consults with MG/IPAs, physicians, providers, members, and other resources, as appropriate, to assess, plan, facilitate implement, coordinate, monitor and evaluate options and services required to meet clinical quality improvement project objectives; uses available resources to promote high quality and cost effective outcomes.

Perform on-site medical record reviews to evaluate delivery of care in relation to clinical practice guidelines. Responsible for facilitating and monitoring of assigned quality improvement projects, including the following: Consult with network physicians, Medical Group/IPAs, providers, members, and other resources, as appropriate, to assess, plan, facilitate implement, coordinate, monitor and evaluate options to meet clinical quality improvement project objectives and to promote high quality and cost effective outcomes. Gather information, analyzes and communicates it, and develops recommendations regarding clinical quality improvement projects. Assist in addressing issues related to clinical quality improvement projects for the managed care programs to assure compliance with contractual arrangements, NCQA accreditation requirements, government regulations and employer group expectations. Assist in coordinating internal support functions for assigned clinical quality improvement projects. Analyze statistical reports to evaluate effectiveness of quality improvement projects as well as to identify opportunities for improvement. Cooperate with other members of the department and interfacing departments as a team to increase overall efficiencies in an effort to maintain or decrease administrative costs. Provide ongoing documentation of clinical quality improvement project interventions for quarterly and annual Quality Improvement Reports, and for accreditation reviews ensuring reporting accuracy and timeliness. Present clinical quality improvement project results to the Quality Improvement Workgroup and Managed Care QI Committee. Participate in physician and Medical Group/IPA trainings such as Managed Care Roundtables, Administrative Forums, and MG/IPA QI Trainings. Coordinate and provide interface with medical groups and other practitioners regarding existing and proposed clinical quality improvement initiatives. Maintain and enhance knowledge of clinical nursing and regulatory standards by attending seminars, training sessions, etc. Performs ongoing monitoring of quality of care and/or critical incidents to assure compliance with accreditation and regulatory requirements. Attend internal/external meetings to keep apprised of quality improvement and managed care issues/information. Assist in day-to-day activities in an effort to achieve HCM or GPD annual divisional goals, as appropriate. Practice within the scope of licensure and/or certification and NCQA accreditation standards. Communicate and interact effectively and professionally with co-workers, management, customers, etc. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. Maintain complete confidentiality of company business. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.