General Summary of Position
Participates in the continuous systematic monitoring of all MedStar Family Choice participating provider processes and outcomes; directs problem focused studies; implements and maintains department objectives to ensure compliance of NCQA accreditation, Federal/State regulations, licensing or reviewing agency requirements; liaison for Quality Improvement Committees. The ideal candidate should be a critical thinker with practical experience in patient care, public health, quality improvement and the assessment of quality improvement initiatives, as well as writing for diverse audiences and can independently assess which data management and statistical strategies when needed to optimally report outcomes. The candidate should also have the ability to assess medical records and make determinations on clinical criteria with policies and procedures.
We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
Primary Duties and Responsibilities
Actively participates in the development and completion of the annual QI Plans and QI Appraisals. Prepares annual Performance Improvement Plan (PIP), and Quality Improvement Activity Analysis (QIA's).Analyzes the Provider Satisfaction Survey and CAHPS survey results and report findings to QI/UM committee. Analyzes complex data and information to provide meaningful results, identifying success factors and improvement opportunities, recommending potential solutions to assist the business set strategic goals.Assists with development and maintenance of MedStar Family Choice's Quality Improvement Program via input with the annual Quality Improvement plan and appraisal.Attends and contributes content to the monthly Quality Improvement staff meetings. Assists the Quality Improvement Manager in maintaining accurate and thorough meeting minutes. Attends the Quality Improvement and Utilization Management Committee (QI/UM) meetings and other meetings as directed.Contributes to member and provider newsletters as well as MFC website content.Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.Serves as a liaison between MFC and the Maryland Department of Health's EPSDT nurse in order to disseminate updated EPSDT regulations to the Provider Relations department and our providers. Coordinate with the state to ensure the EPSDT auditors have access to MFC medical records. Analyzes the EPSDT survey results and report findings to QI/UM committee.Follows the established protocol for reporting any quality issues identified. Develop project initiatives, process and performance measures for Quality Management and deliverables to ensure positive outcomes defined by corporate objectives and NCQA and regulatory regulations.Subject Matter Expert for COMAR regulations and Systems Performance Review activities and actively participates in evaluating MedStar Family Choice's compliance with the regulations and standards. Provides cross departmental input in gathering required materials in support of SPR activities and follows up on audit findings. Uploads all required materials into the Maryland Department Health's online portal.Actively participates in the HEDIS audit by attending/leading HEDIS trainings, gathering required records, abstracting pertinent medical record data, entering data into the HEDIS software database, and performing peer audits. Attend HEDIS pro-Active meetings and remain current on annual updates up to and including medical record review, QI data analysis and reporting, conducting clinical audits and tracers, Physician Advisor interaction, and special projects which are coordinated and directed by the QI/UM Team Leader, Manager, or Director.Participates in the design and implementation of multidisciplinary quality improvement projects as determined by MFC.Collaborates with the Quality Improvement Manager to ensure that all components of the QI Standards for NCQA accreditation are met. Remain current on annual updates.Investigates quality of care events for MFC members, summarizes findings, and reports cases to the MFC Quality of Care Peer Review Committee (QOC). Organize and attend monthly QOC meetings, maintain confidential meeting minutes, and report the QOC activities to the QI/UM committee. Ensure that all applicable cases are forwarded to the Credentialing Department for tracking and trending.Investigates quality of care events for MedStar Family Choice members, summarize findings, and collaborate on cases with the MedStar Health Plans Medical Director. Report quality of care activities to the QIC quarterly meetings. Function as a liaison to the State of Maryland and the Maryland Department of Health for quality improvement matters on an as needed basis.Provides feedback to healthcare providers to apprise them of services that are still needed for patients in order for them to be compliant. Works directly with provider offices to inform them of their Quality and performance on HEDIS measures and educates them on opportunities for improvement. Travel to offices may be required.Provides oversight to assigned delegated entities and reports finding to the QI/UM committee. Evaluates the annual plans, appraisal, quarterly reports, claims and other issues as they arise. As issues arise, assists with the development of a Corrective Action Plan.Revises QI policies and procedures annually.Performs other duties as assigned.
Minimum Qualifications
Education
- Bachelor's degree in healthcare field (BSN) preferred
Experience
- 3-4 years Healthcare experience required and
- Quality improvement experience preferred
Licenses and Certifications
- RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in Maryland. Upon Hire required and
- CPHQ - Certified Professional in Healthcare Quality CPHQ Upon Hire preferred
Knowledge, Skills, and Abilities
- Effective verbal and written communication skills.
- Ability to follow verbal and written instructions.
- High degree of computer proficiency.
- Ability to establish priorities, self-motivated, works independently and follow instructions with supervision.
This position has a hiring range of $87,318 - $157,289
