Healthcare - Healthcare - Senior Quality Improvement Specialist Registered Nurse

Job Summary:
Quality Management function implements, oversees, and maintains new and existing healthcare quality monitoring activities and programs; ensures quality monitoring audits and investigations are performed in accordance with prescribed quality standards; informs data collection, reporting, and analysis to monitor key quality management activity; and provides direction and implementation of federal/state quality management compliance activities.

Job Duties:
The Sr Specialist, Quality Management (RN) contributes to the quality management functions.
Performs quality monitoring activities, including audits of medical record quality, services and service sites, health and safety, and follow-up of monitoring of placement settings.
Implements key quality strategies that require a component of near real-time clinical decision-making. These activities may include initiation and management of interventions (e.g., improving patient safety); preparation and review of potential quality of care and critical incident cases; review of medical record documentation for credentialing and model of care oversight; and any other federal and state required quality activities.
Supports the creation and ongoing revision of policies and procedures reflective of state requirements for all quality management functions, including quality monitoring audits, credentialing and recredentialing, quality of care concerns, and peer review.
Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately in order to present results to key departmental management and other departments as needed.
Monitors and ensures that key quality activities are completed on time and accurately in order to present results to key departmental management and other departments as needed.
Adheres to written documentation and business practices (e.g., policies and procedures, desk-level procedures, manuals, and process flows) that explain the business requirements and how the unit operationalizes those requirements.
Adheres to structure and processes for tracking and trending reportable incidents, quality of care events, member service concerns, and mortalities.
Evaluates project/program activities and results to identify opportunities for improvement.
Is well-versed in the requirements of the quality management program and day-to-day work processes to support compliance with state contract, policies, and program requirements.
Surfaces to Manager and Director any gaps in processes that may require remediation. In particular, the Senior Specialist may be asked to focus on parts of the process where a clinician's perspective would be valuable to uncover process gaps or limitations.
Ensures individual and systemic quality of care investigations are performed timely, accurately, and in accordance with state-based requirements.

Required Education:
Bachelor's Degree or equivalent combination of education and work experience.
AZ RN License

Day to Day Responsibilities:
Quality provider audits

Required Years of Experience: Required Experience/Knowledge, Skills & Abilities

• Min. 3 years experience in healthcare with minimum 1 year experience in quality management and clinical quality investigations, or equivalent experience.
• Critical thinking skills.
• Strong communication skills, both verbally and written.
• Ability to interact effectively with health plan clinical leaders and peers across the organization.
• Proficient in Microsoft Office tools (Outlook, Excel, etc.)