Senior Clinical Quality Care Analyst

  • location: Dayton, OH
  • type: Contract
easy apply

job description

Senior Clinical Quality Care Analyst

job summary:
Reviews clinical quality of care issues, identifies trends, reviews & tracks potential member risk, case referrals to other departments as appropriate. Prepares reports for Leadership.

location: Dayton, Ohio
job type: Contract
work hours: 9am to 5pm
education: Bachelors

· Experience with clinical case reviews (diverse clinical experience as a nurse)

· Strong organizational & communication skills.

· Knowledge of Quality Improvement / NCQA standards.

- Review, track and trend QI and grievance issues for all programs and in all states in addition to prep work for Quality Executive Committee (QEC)

- Maintain reports for QI trends and metrics, as well as prepare reports for Delegation Oversight

- Ensure all clinical quality issues are resolved within specified timeframes as indicated by the states served and programs therein, CMS and all accrediting entities

- Perform reviews, tracking and trending of Potential Member Risk (PMR) cases, referring appropriate cases to Fraud & Abuse and preparing reports for presentation to senior management

- Review and maintain compliance of Quality Improvement policies with NCQA standards

- Maintain case files for all Quality of Care (QOC) issues

- Assist management with annual Encounter Data Validation (EDV) studies

- Request medical records, review documentation and assign a severity level to each Quality of Care case or forward to appropriate medical/dental/specialty reviewer

- Maintain SharePoint database of QOC cases

- Appropriately refer QOC cases to Fraud & Abuse

- Act as liaison with the Case Management and Behavioral Health

- Develop materials and provide education on the reporting of Quality of Care Grievances and Sentinel Events to other appropriate departments

- Function as a resource for educating and resolving questions related to documentation requirements for QOC issues

- Assist the Provider Relations staff with corrective action plans (CAPs) for affected providers

- Review QOC cases, as needed, with the Medical Director/Chief Medical Officer (CMO) and carry out actions as indicated by the CMO

- Maintain accurate individual Excel spreadsheet, showing the status of each open QOC case

- Track and monitor provider QI issues for monthly reporting of provider re-credentialing to Network Operations

- Perform External Quality Review (EQR) record retrieval, research record and review

· Reviews Providers up for Credentialing for previous infractions

- Maintain and appropriately update Clinical Practice Guidelines on a quarterly basis

- Conduct performance improvement studies for various areas

- Assist in the development of work plans and measurement strategies including those of other departments


§ Associates of Science in Nursing is required

§ Bachelor of Science in Nursing (BSN) is preferred

§ Minimum of three (3) years of experience in Quality Improvement, Project Management, Case Management or Utilization Review required

§ Minimum of three (3) years Managed Care experience is required

§ Minimum of two (2) years of accreditation experience is required

§ Minimum of three (3) years of diverse clinical experience as an RN is preferred

§ NCQA, URAC and/or HEDIS experience is preferred

skills: Knowledge/Skills:

§ Proficiency in Microsoft Excel, Access and Word

§ Intermediate skill level with SharePoint

§ Knowledge of state requirements related to Quality Improvement

§ Knowledge NCQA standards

§ Strong written and verbal communication skills

§ Ability to work independently and within a team environment

§ Familiarity of the healthcare field

§ Knowledge of Medicaid and Medicare

§ Effective listening and critical thinking skills

§ Strong interpersonal skills and high level of professionalism

§ Effective problem solving skills with attention to detail

§ Ability to develop, prioritize and accomplish goals

§ Technical writing skills

§ Ability to coordinate complex projects and multiple meetings

§ Ability to work with a variety of disciplines and levels of staff across departments

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

easy apply

get jobs in your inbox.

sign up

related jobs

    Sr Maintenance Engineer

  • location: Middletown, OH
  • job type: Permanent
  • salary: $57,000 - $63,000 per year
  • date posted: 10/20/2020