Specialist, Sr. Clinical Quality
Company: CareFirst, Inc.Categories: Health Care, QA - Quality Control
Job description:PURPOSE: The Senior Clinical Quality Specialist supports the Quality Improvement (QI) Program by planning for and implementing quality improvement, patient safety, and health promotion activities. The incumbent acts as project leader for initiatives that frequently involve other departments and external entities and vendors.
PRINCIPAL ACCOUNTABILITIES:
Under the general direction of the Quality Improvement Manager, the incumbent’s accountabilities include, but are not limited to, the following:
60%
- Quality Improvement, Patient Safety, and Health Promotion Programs: Coordinates and facilitates quality projects and activities in compliance with CareFirst’s mission, national accreditation standards, and state requirements.
- Acts as project leader and/or participates substantially in at least one major quality improvement project, such as health improvement, work place wellness, primary or secondary prevention, patient safety, HEDIS, behavioral health, or delegation oversight.
- Applies nursing judgment in all phases of clinical projects, including planning, implementing and assessing outcomes.
- Coordinates, facilitates, documents, and reports all aspects of assigned project(s).
- Applies QI principles and tools to complete quality initiatives (data collection, quantitative and qualitative analysis, conclusions, action planning and implementation, re-evaluation for effectiveness of interventions).
- Assists department director and/or manager in preparing documentation for national accreditation and state certification reviews.
- Provides oversight to associates within the department and in other operational areas, as needed, to accomplish project goals and objectives.
- Provides interim and annual reports to QI committees.
- Performs other duties as assigned.
20%
- Presentations and Written Materials: Provides oral and written presentations/ materials in support of the QI program.
- Plans, develops and delivers presentations on quality-related topics for internal and external audiences.
- Responds to RFPs and RFIs.
- Composes member and provider newsletter articles.
- Participates in the review and revision of other materials, such as member handbooks and provider manuals.
10%
- Performance Standards/Criteria and Policies/Procedures: Using nursing knowledge and judgment, develops and/or reviews and revises clinically-related performance standards, criteria, and policies and procedures.
- Develops new performance standards, criteria, or policies and procedures as outcomes of quality improvement initiatives or projects.
- Reviews and revises existing performance standards, criteria, and policies and procedures at least annually.
- Presents recommended performance standards, criteria, and policies and procedures to QI Director and/or QI committees, as appropriate.
- Creates new data collection tools, as needed, to support performance standards and criteria.
10%
- QI Committees: Coordinates and facilitates QI-related committees.
- Confers with Medical Director, QI Director, QI Manager, and committee chairperson, as applicable, to establish agenda and prepare meeting materials.
- Documents accurate, contemporaneous meeting minutes.
- Completes timely follow-up on action items.
SUPERVISORY RESPONSIBILITY: This position includes functional oversight of the work of clinical and non-clinical staff in support of the Quality Improvement Program. The position does not have direct reports.
SCOPE DATA: Accountable for recommending, coordinating, and implementing cross-divisional quality improvement activities that may affect members, practitioners, providers, vendors, delegates, and/or the Plan. Responsibilities primarily involve the HMO and PPO lines of business, but may affect all lines of business. Accountable for producing documents for internal and external distribution. Failure to perform the job well could result in:
- A change in the Plan’s national accreditation status; and/or
- Federal or state sanctions.
- Loss of contracts
Required:
- Licensed registered nurse in Maryland, Virginia or the District of Columbia
- Bachelors degree or equivalent experience
- Minimum of 3 years of clinical experience
- Minimum of 3-4 years experience in quality improvement in a managed care environment
- An independent means of transportation (local travel required)
Abilities/Skills:
- Knowledge of quality improvement principles and tools
- Ability to interpret national accreditation standards and federal/state certification requirements
- Analytical and statistical skills to interpret data and draw conclusions
- Project leader and management skills
- Critical thinking and sound judgment
- Strong verbal and written communication skills; ability to write detailed reports for various audiences
- Strict attention to detail
- Initiative and ability to work independently and with others in a team
- Ability to positively interface with internal staff and external providers
- Demonstrated proficiency with various computer applications/software, including but not limited to: (text, spreadsheet, relational database) and mainframe data sources
Preferred:
- Masters degree or equivalent experience
- Certification in QI (CPHQ)
- Experience with accreditation survey process
- Previous supervisory experience in health care environment
PHYSICAL DEMANDS:
The physical demands described below are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Frequent driving is required.