Quality Improvement Specialist

Overview

Conducts, coordinates and monitors quality activities and initiatives for one or more products of the Health Plan. Maintains, monitors, and develops strategies for the evaluation of member and/or patient care services. Analyzes findings and recommends performance improvement initiatives and/or corrective actions. Identifies performance and process improvement opportunities to improve HEDIS/QARR, Star ratings and Incentive programs, as applicable. Assists management with ensuring compliance with regulatory requirements for all products. Works under general direction.

Compensation:

$77,200.00 - $96,500.00 Annual

• Develops performance measures, designs data collection instruments, and conducts quality, compliance and utilization reviews. • Ensures Quality Improvement programs are aligned with CMS Triple Aim framework: improving the patient’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare. • Collects and analyzes data, identifies trends, writes reports and presents findings to appropriate committees, managers and/or staff. • Prepares, coordinates, and participates in QM Committees and subcommittees as directed. • Participates in the coordination, review and approval of policies and procedures for VNS Health Plans and its delegated entities. Identifies gaps and recommends creation of new policies. • Serves as a resource and provides expertise and assistance on quality improvement projects. • Collaborates with clinical management to identify, develop and implement quality improvement standards and criteria that meet program goals. Evaluates effectiveness of standards and recommends changes, as needed. • Assists with analysis of member satisfaction surveys and audits including but not limited to the CMS Health Outcomes Survey, Consumer Assessment of Health Care Providers and Systems or internal satisfaction surveys. Collaborates with Health plan staff to develop initiatives and action plans to improve member satisfaction. • Keeps informed of the latest internal and external issues and trends in utilization and quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. • Participates in the development and implementation of quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, NYSDOH QARR, Quality Scorecard, IPRO Projects, and CMS Quality Projects. • Participates in the preparation for and assists with site visits of outside surveyors/regulators for the purpose of regulatory compliance and accreditation. • Participates in special projects and performs other duties as assigned.
Qualifications
Licenses and Certifications:
License and current registration to practice as a registered professional nurse in New York State preferred Current registration to practice as a Licensed Social Worker in New York State preferred

Education:
Bachelor's Degree in Healthcare Administration, Public Health, Business or other related healthcare field or the equivalent work experience required Master's Degree preferred

Work Experience:
Minimum of three years quality improvement experience in a health plan or health care, setting required Demonstrated leadership experience preferred Excellent oral, written and interpersonal communication skills, including group facilitation skills required Knowledge of basic Performance Improvement tools and methodologies preferred