Quality Management Specialist

ESSENTIAL FUNCTIONS

Perform on-site medical record reviews to evaluate delivery of care in relation to Enterprise clinical practice guidelines. Responsible for facilitating and monitoring of assigned quality improvement projects, including the following: Consult with network physicians, Medical Group/IPAs, providers, members, and other resources, as appropriate, to assess, plan, facilitate implement, coordinate, monitor and evaluate options to meet clinical quality improvement project objectives and to promote high quality and cost-effective outcomes. Gather information, analyzes and communicates it, and develops recommendations regarding clinical quality improvement projects. Assist in addressing issues related to clinical quality improvement projects for the managed care programs to assure compliance with contractual arrangements, accreditation requirements, government regulations and employer group expectations.Assist in coordinating internal support functions for assigned clinical quality improvement projects. Analyze statistical reports to evaluate effectiveness of quality improvement projects as well as to identify opportunities for improvement.Cooperate with other members of the department and interfacing departments as a team to increase overall efficiencies in an effort to maintain or decrease administrative costs.Provide ongoing documentation of clinical quality improvement project interventions for quarterly and annual Quality Improvement Reports, and for accreditation reviews ensuring reporting accuracy and timeliness. Present clinical quality improvement project results to the Quality Improvement Workgroups and Managed Care QI Committees.Participate in physician and Medical Group/IPA trainings such as Managed Care Roundtables, Administrative Forums, and MG/IPA QI Fund Trainings.Function as preceptor for orientation of new employees.Coordinate and provide interface with medical groups and other practitioners regarding existing and proposed clinical quality improvement initiatives. Assist in meeting and interfacing with outside agencies and organizations such as Illinois Department of Public Health, American Academy of Pediatrics, American Diabetes Association, etc. Maintain and enhance knowledge of clinical nursing and regulatory standards by attending seminars, training sessions, etc. Attend internal/external meetings to keep apprised of quality improvement and managed care issues/information. Assist in day-to-day activities in an effort to achieve HCM annual divisional goals.Practice within the scope of licensure and/or certification and accreditation standards.Communicate and interact effectively and professionally with co-workers, management, customers, etc.Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.Maintain complete confidentiality of company business.Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:Registered Nurse (RN), Licensed Practical Nurse (LPN), Respiratory Therapist, or other medical specialty, i.e. Physician's Assistant, Corpsman with unrestricted license in state.3 years clinical practice experience.2 years UM, Case Management, quality improvement and/or project management experience.Experience conducting presentations for member and/or provider training.Current Illinois driver's license.Ability to travel including overnight stays.Verbal and written communications skills.Data analysis experience.PC proficiency to include Word, Excel, and PowerPoint.