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Quality Improvement - Manager - RN

Company: WellCare
Location: Chicago
Posted on: January 14, 2018

Job Description:

Conducts oversight and management of Accreditationinitiatives, state and regulatory quality compliance, HEDIS and
quality improvement initiatives for PiPs, QiPs, QIA's, delegation
audits and external quality reviews .Applies medical knowledge and
analytical skills to effectively and efficiently coordinate quality
activities and improve performance metrics of organizational
goals.DEPARTMENT: Health
Services-Quality ImprovementREPORTS TO:
Director, Quality ImprovementEssential
Functions:Develops,
implements and maintains a standardized quality management plan and
program to ensure compliance with external regulatory and
accreditation requirements.Establishes and
maintains tracking and monitoring systems for health care quality
improvement activities according to regulatory requirements,
accreditation standards, policies and procedures and contractual
agreements.Ensures high risk, high volume, and
unusual events are monitored concurrently and retrospectively as
they occur.Researches and develops performance
measurement and outcome studies to assess and improve the health
status of the membership.Plans, organizes and
manages the design, development and analysis of a wide variety of
topics relevant to health care
services.Designs and develops methodologies
for preventive care and health care evaluations.Researches and
documents current health care standards for use in study design and
methodologies.Conducts preventive studies to
evaluate the continuity and coordination of care and to assess the
quality and utilization of health care
services.Provides assistance and guidance to
clinical staff with regard to study design, methodology, data
analysis and reporting.Manages and evaluates
performance of staff related to clinical and health care services
performance improvement activities.Provides
department orientation to new staff and ongoing staff development
to the entire department.Coordinates
guidelines, studies and performance improvement activities in
concert with the utilization management, quality management,
pharmacy services, case management and disease management
programs.Maintains a knowledge base of HEDIS
requirements and implementing clinical performance methods to
improve HEDIS performance.Prepares, compiles,
reviews and submits monthly and quarterly reports for quality
committee meetings.Coordinates all external
programmatic oversight visits for contracted providers and ensures
timely completion and follow up on corrective action
plans.Participates in the development, review
and updating of policies and
procedures.Develops and analyzes reports to
monitor and evaluate quality performance in meeting established
goals related to quality improvement plan and contractual
requirements.Provides guidance and training to
new associates.Performs other duties as
assigned.Additional
Responsibilities:Completes the
state Licensed Health Care Risk Management certification
program.Performs annual update on state 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
state Plan quality committee structure and Board of
Directors.*LI-SM1
Candidate
Education:Required a Bachelor's
Degree in HealthCare, Nursing, Public Health, Health Administration
or directly related degree or equivalent work
experiencePreferred a Master's Degree in
Healthcare, Nursing, Public Health, Health
AdministrationCandidate
Experience:Required 5 years of
experience in directly related Quality Improvement job
dutiesRequired 3 years of experience in
managed careRequired 1 year of management
experienceRequired excellent knowledge of
JCAHO, URAC, AAAHC and NCQA standardsPreferred
experience with
Medicaid/MedicareCandidate
Skills:Intermediate knowledge of
community, state and federal laws and
resourcesAdvanced demonstrated written
communication skillsAdvanced demonstrated
interpersonal/verbal communication
skillsAdvanced demonstrated analytical
skillsAdvanced demonstrated problem solving
skillsIntermediate ability to work in a fast
paced environment with changing
prioritiesIntermediate ability to
multi-taskAdvanced ability to effectively
present information and respond to questions from families,
members, and providersAdvanced ability to
effectively present information and respond to questions from peers
and managementIntermediate ability to
influence internal and external
constituentsIntermediate ability to
lead/manage othersLicenses and
Certifications:A license in one of the
following is required:Required for
IL/MO RN LicensePreferred Licensed Registered
Nurse (RN)Preferred Certified Professionals in
Healthcare Quality
(CPHQ)Technical
Skills:Required intermediate
Microsoft ExcelRequired intermediate Microsoft
WordRequired intermediate Microsoft
VisioRequired intermediate Microsoft
PowerPointRequired intermediate Microsoft
OutlookRequired intermediate Healthcare
Management Systems
(Generic)Languages:Bilingual
helpful

Keywords: WellCare, Chicago, Quality Improvement - Manager - RN, Healthcare, Chicago, Illinois

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