Senior Clinical Quality Care Analyst

  • location: Dayton, OH
  • type: Contract
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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
 
responsibilities:
Skillsets:

· 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

 
qualifications:
Education:

§ 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.

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