POSITION SUMMARY

The Quality Improvement (QI) Specialist will serve a key role in assessing and improving quality performance for regional healthcare services in compliance with policies, quality standards, workflow procedures, and regulatory and accreditation requirements. The incumbent will perform quality assurance and improvement activities including analyzing and organizing data to identify regional trends, conducting root cause analyses to identify areas for improvement, developing and implementing improvement strategies, conducting audits of various crucial records and processes, maintain detailed records, prepare written and visual reports, and monitor results to support optimal outcomes and continuous innovation and compliance. This position will work in collaboration with Practice Transformation Coaches to support and participate in performance improvement projects with providers.

DUTIES PERFORMED

• Track, trend, analyze, and report on regional and provider-level performance metrics.
• Identify root causes, design and implement improvement strategies, and analyze impacts/improvement.
• Support clinic-level performance improvement activities in collaboration with Practice Transformation and other administrative efforts.
• Conduct a variety of audits spanning physical health and behavioral health records, subcontractor compliance against contractual requirements, and organizational adherence to state contracts.
• Support tracking serious adverse events, coordinating with Provider Relations, Member Services, Quality, Clinical Teams, the state, and regulatory agencies when necessary while adhering to timeliness standards.
• Audit practice records for completeness, accuracy, and appropriateness. The audits may include but not be limited to ensuring records include the minimal required data, comparing source data to the records for accuracy, and analyzing select data in detail.
• Identify opportunities to improve the quality of records, efficiency of processes, and increase performance.
• Participate in the preparation, facilitation, and follow up activities for regulatory and accreditation surveys.
• Audit records and processes related to general department functions including, but not limited to, billing, coding, training records, timekeeping, policy management, and regulatory records.
• Maintain detailed auditing data including workload details and documented audit findings, recommendations, and corrections in a manner that will allow this data to be categorized, tracked, and trended for analytics.
• Coordinate and manage quality-related projects, including organizing and tracking audit activities for contracted providers to ensure compliance with organizational and regulatory standards.
• Participates in key meetings and completes other duties as assigned.

KNOWLEDGE/SKILLS/ABILITIES

• Bachelor’s degree in business administration, science, health care, public health, or other life sciences related field
• Certified Lean Six Sigma Green Belt, Certified Professional in Healthcare Quality, or related certification preferred

Experience:

• For bachelor’s degree, applicants must have 3 years of experience in areas identified below. Project or contract management of similar scope and size
• Experience with managed care insurance systems in behavioral and/or physical healthcare preferred.
• Experience with working on projects that serve Medicaid populations preferred.

• Proficiency in software applications that include, but are not limited to Microsoft Word, Excel, and PowerPoint.
• Must be highly organized with the ability to work well with people.
• Must have ability to work with highly sensitive and confidential information.

Knowledge of:

• Knowledge of quality improvement, quality assurance, quality systems, and/or internal auditing preferred.
• Basic knowledge of data analysis, statistics, data integrity, and analytics with initiative and ability to further develop skills
• Applicable data privacy practices and laws

Skills/Abilities to:

• Ability to work with highly detailed, complex and emotionally sensitive information
• Ability to maintain a high degree of discretion, confidentiality, protection, and integrity
• Ability to learn complex processes, medical terminology, technology systems, and progressively develop data analytics skill set
• Ability to prioritize and complete multiple complex work assignments
• Ability to work independently
• Understand minimal medical terminology
• Excellent written and verbal communication skills
• Ability to provide constructive feedback in a clear, concise, and respectful manner
• Demonstrated ability to meet deadlines

WORKING CONDITIONS