Quality Improvement Specialist, Clinical

Overview

Leads interdepartmental quality improvement activities such as development and engagement, clinical review, clinical risk management, and patient satisfaction. Serves as a resource to quality improvement committees and work groups. Analyzes outcome reports. Implements, directs and evaluates a system for quality improvement program designed to promote and maintain optimal patient care. Manages Health Plans quality improvement activities and assures quality clinical and non-clinical compliance with regulatory authorities. Works under general direction.

Responsibilities
• Conducts clinical assessment including and not limited to, medication reconciliations, post-discharge transitions of care assessment and follow-up post emergency department assessment • Collaborates with programs to assure compliance with DOH/CMS/NCQA requirements. Coaches, facilitates and monitors continuous improvement to attain strategic quality objectives and industry benchmarks for patient outcomes, satisfaction cost and regulatory requirement. • Conducts clinical reviews with primary care providers or specialist to address non-adherence and/or clinical diagnosis for HEDIS/QARR exclusion. • Participates and leads improvement teams and projects and other committees related to performance improvement, measurement and documentation. • Performs audits on medical records and provide counseling/guidance to PCPs on VNS Health Medical Record Documentation Standards. • Conducts audits of patient care records. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient care review, including the design, testing and evaluation of the review methodology. • Performs utilization and quality assessment reviews to maintain compliance with Federal and State regulatory requirements. Identifies & analyzes results to inform the development of correction plans. • Develops action plans in collaboration with management staff based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies. • Participates in the preparation for and assists with site visits of outside provider for the purpose of regulatory quality compliance. • Investigates patient related complaints, at the direction of the Director. Prepares related reports of investigations and recommendations for correction/improvement. • Develops training materials for and spreads protocols/standards for patient populations within a collaborative framework. • Conducts follow-ups and reassessment and reports findings to evaluate whether corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively. • Develops processes, policies and procedures related to current practice and changes in regulatory and industry requirements. Collects and feeds back data on performance improvement for teams within a region/program. • Participates in special projects and performs other duties as assigned.
Qualifications
Licenses and Certifications:
License and current registration to practice as a Registered Professional Nurse in New York State required License and current registration to practice as a Nurse Practitioner (NP) in New York State preferred

Education:
Bachelor's Degree Nursing required Master's Degree Nursing preferred Enrollment in accredited program within first year and completion of Bachelor’s degree in Nursing by 2015 from a program approved by the New York State Department of Education required

Work Experience:
Minimum of three years quality improvement experience in a health plan or health care, setting required Minimum of one year experience, quality management, practice improvement and compliance preferred Demonstrated leadership experience preferred Excellent oral, written and interpersonal communication skills, including group facilitation skills required Knowledge of basic Performance Improvement tools and methodologies preferred

About the Company:
VNS Health