AmeriHealth Caritas Quality Perform Specialist - Clinical in Charleston, South Carolina
Quality Perform Specialist - Clinical
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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.
As part of the Quality Management team, the Quality Performance Specialist – Senior is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing of care standards. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and, Clinical Practice Guidelines. The position also supports accreditation and clinical quality performance improvement activities.
- Assumes responsibility for reviewing all sentinel events and member concerns reported for potential quality of care issues. Coordinates reviews with physician advisors and clinical quality committees as appropriate.
- Assures minimally necessary medical records are collected and organized for clinical review to occur. Summarizes all clinical findings for review by clinical committees as appropriate.
- Prepares meeting packets, schedules meetings, develops agendas, completes minutes, and chairs the Internal Quality Review Committee (IQRC).
- Maintains database to support trending and reporting of adverse outcomes resulting from clinical care provided.
- Develops reports and analysis for semi-annual trending reports and presents to the Quality Medical Management Committee (QMMC) for input and direction. Follows up on any recommendations.
- Maintains QR policies including annual reviews, updates, and approvals.
- Maintains hard copy documentation in accordance with contractual requirements.
- Conducts analysis annually on the Plan’s efforts to improve the safety of members.
- Supports the quality improvement department with annual medical record review activities including HEDIS, Healthy Kentuckians, and Clinical Practice Guidelines by working collaboratively with the Quality Improvement Department. Assistance will be based upon the organizations needs annually but may include participation in the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.
- Associate’s Degree or equivalent work experience.
- Registered Nurse required.
- Minimum of 3 years in clinical or service quality improvement required.
- Minimum of 3 years in healthcare delivery required.
- An unrestricted registered nurse license in the plan’s state or any other state he/she works.
- Prior experience with project facilitation/management preferred.
- Knowledge and understanding of QI functions in an MCO preferred.
- Knowledge of Medicaid and Medicare preferred.
- Proficient with Microsoft Office applications including Word, PowerPoint, Excel required.
EOE Minorities/Females/Protected Veterans/Disabled