Description:

BASIC FUNCTION:

This position is responsible for facilitating all aspects of assigned clinical quality improvement projects, quality auditing, quality reporting; consults with physicians, providers, members, and other resources, as appropriate, to assess, plan, facilitate implement, coordinate, monitor and evaluate options and services required to meet clinical quality improvement project/audits/reporting objectives; uses available resources to promote high quality and cost effective outcomes. This position is responsible for coordinating quality reviews, audits and projects in compliance with accreditation and regulatory agency requirements.

ESSENTIAL FUNCTIONS:

• Perform on-site or electronic medical record reviews to evaluate delivery of care in relation to clinical practice guidelines or state regulations.

• Responsible for facilitating and monitoring of assigned quality improvement projects, including the following:

Consult with network physicians, providers, members, and other resources, as appropriate, to assess, plan, facilitate implement, coordinate, monitor and evaluate options to meet clinical quality improvement project/auditing/reporting objectives and to promote high quality and cost effective outcomes.

Gather information, analyzes and communicates it, and develops recommendations regarding clinical quality improvement projects/audits/reports.

Assist in addressing issues related to clinical quality improvement projects/audits/reports 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/audits/reports.

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 quality improvement workgroups and the Behavioral Health QI Committee.

• Coordinate and provide interface with Behavioral Health providers and other practitioners, as well as the state regarding existing and proposed clinical quality improvement initiatives and results.

• Assist in development, implementation, and evaluation of effectiveness of population based programs. Participate in activities such as literature review to identify appropriate recommendations for quality improvement initiatives, population assessment, and development of data collection tools.

• Facilitate action plan activities related to assigned programs, coordinate with internal and external resources to meet program targets and objectives.

• Assist in preparing accurate reports and program documents including, but not limited to, the QI Program Description, QI Work Plan, and Program Evaluation.

• Assist in meeting and interfacing with outside agencies and organizations such as Illinois Department of Public Health, American Academy of Pediatrics, American Diabetes Association, various state departments, etc.

• Attend internal/external meetings to keep apprised of quality improvement and managed care issues/information.

• Maintain and enhance knowledge of clinical and regulatory standards by attending seminars, training sessions, etc.

• Performs ongoing monitoring of quality of care and/or critical incidents to assure compliance with accreditation and regulatory requirements.

• 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 or GPD annual divisional goals, as appropriate.

• 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) or Masters-level Behavioral Health Professional with independent practice license. License is current, valid in the state of operations and in good standing.

• 3 years clinical practice experience.

• 2 years Utilization Management, Case Management, quality improvement and/or project management experience.

• Experience conducting presentations for member and/or provider training.

• Knowledge of behavioral health or managed care products and programs.

• Current, unrestricted driving license.

• Ability to travel including overnight stays.

• Verbal and written communication skills.

• Data analysis experience.

• PC proficiency to include Word and Excel.

PREFERRED JOB REQUIREMENTS:

• Quality improvement and/or project management experience.

• Behavioral Health experience.

Notes:

This is remote

VIVA USA Inc.

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Registered Nurse - Remote