Quality Improvement Specialist Senior

Job Description

The Senior Quality Improvement Specialist is responsible for coordinating assigned regulatory, accreditation, clinical quality and/or service improvement programs. Functions as a leader for assigned health services initiatives handling multiple large-scale complex initiatives. Collaborates on national, regional and multi-plan initiatives. Develops programs in compliance with accreditation and regulatory requirements/ standards and monitors ongoing program performance to maintain compliance. Acts as a resource for training, policy and regulatory/accreditation interpretation.
Leads and manages multiple complex initiatives that impact the quality or effectiveness of health care delivery and/or health care services provided to members.
Ensures that clinical and service quality improvement programs and initiatives are compliant with applicable accreditation, state and federal requirements.
Conducts an assessment of programs, initiatives and interventions to ensure goals and objectives were met and refine activities, as needed, to improve the effectiveness and improve outcomes.
Develops and submits regulatory reports at the time and in the manner required by state or federal agencies such as CMS.
Conducts vendor oversight and management.
Develops targeted activities to improve Star Ratings, HEDIS, CAHPS, HOS, provider satisfaction and other identified performance measures.
Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas.
Participates in the development and maintenance of annual quality improvement program documents and evaluations, compliance audits, policies and procedures, and improvement activities.
Develops internal reports to demonstrate progress on each initiative/project and presents to senior-level staff. Describes outreach initiatives, potential/experienced barriers and activities to resolve issues and improve outcomes.
Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management.
Identifies areas of improvement within the company and works collaboratively with other departments to develop clinical and non-clinical performance improvement projects.
Researches best practices, national and regional benchmarks, and industry standards.
Develops collaborative relationships with contracted providers or provider groups to promote participation in quality improvement collaboratives to improve clinical care outcomes.
Represents Health Net at external work groups and committees. May lead and/or participate in external activities, work groups or committees when applicable.
Communicates programs, interventions and results to external entities in accordance with applicable program objectives, policies and procedures.
In conjunction with Medical Director, communicates quality improvement initiatives, results, and/or performance data to participating physician groups.
Develops and/or maintains relationships with other external organizations to expand key partnerships.
Assesses current industry trends and regulations for enterprise-wide adoption to assure quality and effectiveness of health care delivery and/or healthcare services provided to members.
Performs all other duties as assigned.