Clinical Quality Resume Samples

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AG
A Gleason
Aidan
Gleason
52344 Maggio Gateway
New York
NY
+1 (555) 969 7505
52344 Maggio Gateway
New York
NY
Phone
p +1 (555) 969 7505
Experience Experience
Houston, TX
Clinical Quality Consultant
Houston, TX
Rodriguez, Bosco and Quigley
Houston, TX
Clinical Quality Consultant
  • Collecting and requesting data to support training department
  • Training will include Stars measures (HEDIS / CAHPS / HOS / med adherence), and Optum program administration, use of plan tools, reports and systems
  • Presenting findings to leadership and department
  • Analyzing data and identify risks
  • Maintaining current and detailed knowledge of Training SharePoint
  • Training will include Stars measures (HEDIS/CAHPS/HOS/med adherence), and Optum program administration, use of plan tools, reports and systems
  • Develop creative solutions for various care management platforms
Philadelphia, PA
Clinical Quality Coordinator
Philadelphia, PA
Ratke LLC
Philadelphia, PA
Clinical Quality Coordinator
  • Underfill Statement
  • Works closely with Quality Analytics and H.I.T.S. to implement electronic support of clinical data to reduce the burden of manual data abstraction, analysis, and reporting
  • Other duties as assigned
  • Demonstrated knowledge regarding clinical quality, (e.g., best practice alerts, clinical guideline development, other clinical quality improvement)
  • Insight and knowledge regarding challenges and pressures facing providers
  • Demonstrated knowledge of process improvement, lean principles, and associated tools and techniques
  • Knowledge of UMHS MiChart EMR system
present
New York, NY
Clinical Quality Lead
New York, NY
Welch Inc
present
New York, NY
Clinical Quality Lead
present
  • Works with Manager/Director to design and/or develop tools for department
  • Contacts responsible department manager when barriers to job performance occur
  • Troubleshoots software/hardware and network-based problems
  • Supports, adapts readily to, and assists in facilitating organizational and departmental change
  • Perform quality checks as assigned
  • Serve as contact for outside agencies as directed by Director/Manager
  • Willingly performs others duties as assigned
Education Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
DePaul University
Bachelor’s Degree in Nursing
Skills Skills
  • Report results (e.g., quality improvement initiatives, audits) to committees, Board of Directors, external stakeholders, regulatory agencies, etc
  • Identify Quality improvement or intervention opportunities and work cross-functionally to develop interventions or recommendations
  • This is an office position in Richmond, Virginia
  • Perform vendor management and oversight
  • Perform stakeholder engagement and communication
  • Monitor, track, and report program key performance indicator metrics
  • Manage program billing/invoicing processes
  • Facilitate and lead cross functional team meetings offering guidance and solutions
  • Serve as Program Manager/Project Lead managing and implementing E&I Member Engagement programs
  • Review results, conduct analyses (e.g., evaluate against goals/effectiveness of interventions over time), and prepare reports on findings for Performance / Quality Improvement Projects
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15 Clinical Quality resume templates

1

Manager of Clinical Quality Resume Examples & Samples

  • Familiarity with HEDIS reporting and NCQA accreditation
  • Prior experience in a quality control function
  • Bachelor's Degree in healthcare or a related field
2

Clinical Quality Consultant Resume Examples & Samples

  • Function as HEDIS subject matter expert in consultation with provider practices
  • Advise and educate provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/CPT coding in accordance with NCQA requirements
  • Hire, onboard and educate local MSO market Clinical leaders and team
  • Work with internal MSO partners to build out role descriptions and training documents
  • Work effectively with the local Humana Market in order to foster continued partnership within the Provider community
  • Work in a consultative role with various departments locally and at corporate headquarters in creating effective information and analyses in order to optimize the MSO’s strategic objectives
  • Active RN license in designated state(s) without restrictions
  • Proven ability to effectively train clinical staff
  • Strong consultation and influencing skills
  • Ability to multi-task and work in a fast paced environment with changing priorities
  • Intermediate ability to implement process improvements
  • Proficient with Microsoft Office applications
  • Ability to travel up to 50% for implementations
  • This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be tested for TB
  • Master’s Degree in Health Care or related field
3

Clinical Quality / Hedis Leader Resume Examples & Samples

  • A minimum of 2 years of experience in directly related HEDIS medical record review and/or Quality Improvement with experience in clinical data/chart reviews and providing clinical consultation and education to providers and provider staff
  • A minimum of 1 year of experience in a managed care health services environment
  • Strong ability to implement process improvements
  • Understanding of data analysis and continuous quality improvement process
  • Experienced leadership demonstrating interpersonal/verbal communication skills
  • Effective consultation and influencing skills
  • Advanced Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Proven Ability to effectively present information and respond to questions from families, members, and providers
  • Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
4

Clinical Quality Program Manager Medicare Resume Examples & Samples

  • Contract and request for proposal input
  • Leading and facilitating trans-departmental collaboration, readiness review, implementation efforts and affiliated presentations and meetings
  • Representing Humana at Home interests to designated organizations, vendors, government agencies e.g. CMS and States
  • Determine synergies and standardization across all programs, while addressing unique plan needs and requirements
  • Key representative of Humana at Home working in collaboration with other Humana departmental leaders
  • Seeking integrated solutions while translating and integrating contract and regulatory requirements, overall company strategy and long-term goals into functional strategy and operational solutions
  • Lead functional direction and initiatives as the basis for functional strategic and tactical planning
  • Define functional strategic goals and objectives
  • Work towards the project plan deliverables, meeting deadlines and requirements
  • Combine broad vision with a critical eye for internal operations and quality
  • Contribute to the success of Humana's business strategy by
  • Minimum five years of clinical leadership experience with proven record of program design and implementation
  • Minimum three years insurance industry experience in Medicare, Medicaid and/or LTC
  • Demonstrated ability to align business, contractual and regulatory requirements in care management program design and implementation
  • Strong ability to translate highly complex requirements into operationally sound, delivery models
  • Highly skilled in ability to foster collaboration and motivate key stakeholders
  • Demonstrates exceptional communication and interpersonal skills, with strong ability to negotiate solutions
  • Ability to travel as required by the business
  • Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work
  • Must have accessibility to high speed DSL or cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 5M x 1M
  • Master's Degree in Business, Health Administration or related field
  • Residence within the Central or Eastern time zone strongly preferred
  • Residence within the states of Illinois, Ohio, Kentucky or Virginia preferred
5

Clinical Quality Process Manager Virginia Dual Demonstration Plan Resume Examples & Samples

  • Manage the clinical quality services for this care management model of care for the Virginia Dual Demonstration Plan
  • Promote continuous quality process improvement
  • Develop and manage a team of Quality Consultants
  • Lead, develop and contribute to quality and clinical program design, implementation and quality related initiatives
  • Monitor clinical program metrics and trends, working to align process improvements to preserve program integrity and clinical efficacy
  • Develop and maintain a Virginia MOC Manual, detailing care management requirements, clinical service level standards and best practice guidelines
  • Oversee and monitor customer or account needs for clinical program integrity and outcomes
  • Contribute to the development of policies and procedures related to clinical, quality and clinical process and documentation
  • Lead and participate in clinical process and program development workgroups and committees
  • Uphold the MOC regulatory compliance requirements per NCQA, HEDIS, CMS, DMAS (State of VA), Humana and others as required
  • Provide administrative oversight, supervision and coaching to assigned reports
  • Bachelor’s degree in related field, Master’s degree preferred
  • Minimum three years of care management/clinical experience, preferably in a managed care setting
  • 3+ years quality, compliance, NCQA accreditation, HEDIS, Special Needs Plans/ Medicare/ Medicaid experience
  • Management/ leadership experience
  • Must reside within the state of Virginia, preferably within geographic area of the Humana Glen Allen office
  • Master's degree from accredited university or college
  • Prior clinical quality strategy/ clinical program design experience; prior management, regulatory compliance and/or quality assurance experience such as NCQA accreditation, HEDIS, complex care management/ experience, Medicaid and Medicare
  • Demonstrates exceptional communication and interpersonal skills; ability to interact effectively with multi-disciplinary team members, customers and management
  • Demonstrated ability to align and motivate key process stakeholders, including nurses, physicians, and other clinical/administrative staff within and external to Humana at Home
6

Clinical Quality Data Abstractor Quality & Outcomes Management Hour Days Resume Examples & Samples

  • Knowledgeable about existing programs available for data validation and data cleansing and have experience with high-level analytical tools and data formats
  • At least 3 years’ experience in a healthcare environment, preferred
  • Demonstrated ability to adapt easily to change and lead others in a team environment
7

Clinical Quality Data Abstractor Resume Examples & Samples

  • Experience in supporting the data preparation requirements of an interdisciplinary team in a large-scale healthcare environment
  • Experience with, methods required to optimize the acquisition, storage, retrieval, and use of information in a healthcare environment
  • Demonstrate well developed and proven organizational, problem solving, analytical, customer service and oral and written communication skills
  • Familiarity with quality and risk databases commonly used in a hospital setting
8

Clinical Quality & Stars Maximization Stars Consultant Resume Examples & Samples

  • Own the Initiative Approval process and seek continuous improvement
  • Lead the focus on measurement of Initiatives and continuous improvement
  • Manage the internal communication of progress and results
  • Manage the annual and monthly budget needs
  • Work with Competitive Intelligence on scope of projects to assist in improving performance
  • Act as knowledgeable point of contact, able to assist with Stars education, training and support activities for new MSDs and/or key Stars participants within the markets
  • Support executive communication as needed (e.g., 15% Solution meeting)
  • Ability to partner and influence virtual teams
  • While not staffed to provide analyst or administrative assistance, make every effort to support ad-hoc needs and requests
  • Proven track record of managing projects and processes
  • Ability to interpret and leverage data to improve strategy and make recommendations
  • Leverage reports and lead analysis to identify opportunities and assess progress to goals
  • Demonstrated experience building and maintaining relationships
  • Proven facilitation skills and influencing others
  • Entrepreneurial in thinking and acting
  • Proven presentation skills (creating content and presenting to all levels of the organization)
  • Familiarity in development of metrics and objective measurement
  • Possess a solid understanding of operations, technology, communications and processes
  • Proficiency in Microsoft Office Applications: Word, Excel, PowerPoint
  • PMP certification a plus
  • Process mapping and process management experience a plus
  • Six Sigma Certification also a plus
9

Clinical Quality Consultant Resume Examples & Samples

  • Qualify, prioritize, and concentrate Provider visit efforts on top opportunities
  • Develop, facilitate, and/or secure opportunities to positively impact Triple Aim
  • Maintain client relationships, effectively address provider needs & PODS goals
  • Understand the business, industry, and industry trends and use knowledge to recommend effective solutions
  • Lead and/or support collaborative business partnerships, elicit client understanding and insight to advise and make recommendations
  • Clarify scope of work commitments and deliverables, and define measurable success criteria to monitor progress toward goals
  • Deliver provider specific metrics and coach providers on gap closing opportunities
  • Facilitate patients’ participation in clinical programs & identify opportunities member participation
  • Define gaps in Humana’s service relationship with providers and facilitate resolution
  • Identify specific practice needs where Humana can provide support
  • Coach provider office staff on best means to communicate with Senior members that may have hearing, vision, physical abilities challenges
  • Develop, enhance and maintain provider clinical relationship across product lines
  • Establish and foster a healthy working relationship between practice and Humana
  • Partner with physicians/physician staff to find ways to explore new ways to encourage member clinical participation in wellness and education
  • Provide resources and educational opportunities to provider and staff
  • Capture concerns/issues in action plans as agreed upon by Provider & PODS Owner
  • Document action plans and details of visits and outcomes within CGX
  • Look beyond metrics to identify underlying issues that contribute to gaps
  • Prioritize Analyst work for PODS specific reporting
  • Accountable for Provider Prioritization & communication of priorities to PODS team
  • Facilitate regular Provider Engagement Strategy meetings
  • Accountable for development of Provider specific Care Plans
  • Assess data, identify opportunities, and understand how the PODS drives successful Triple Aim outcomes
  • Role Essentials
  • An active RN license in the designated state
  • Strong interpersonal & relationship building skills
  • Strong influencing, listening, and consultative skills
  • CMS Stars/performance measures/HEDIS knowledge and experience
  • Provider and member rewards program knowledge and experience
  • Bachelor’s degree in a related field
  • Proven leadership/supervisory/management experience
10

Clinical Quality Program Consultant Resume Examples & Samples

  • Assist internal and external stakeholders with design and deployment of any Humana At Home clinical programs
  • Communicate and collaborate with market leadership, providers and corporate cross-functional team contacts to provide subject matter expertise for program implementation
  • Develop and/or update as appropriate detailed process flows and program documents Work closely with program stakeholders to implement clinical and operational processes, facilitating work groups and meetings
  • Expert developer and contributor to both written and oral communications and resources detailing the clinical program
  • Document highly complex business/clinical processes and contribute to policy and procedure content and development, compliance and quality documentation, including policy and process flows
  • Contribute content and objectives to core curriculum, user materials/resources and training
  • Provide oversight for Clinical Program Evaluation as appropriate and assigned
  • Facilitate and participate in corporate cross-functional team related meetings and activities and serves as a clinical program subject matter expert
  • Participate in meetings, calls and strategy/ workgroup sessions as assigned
  • Uphold the MOC regulatory compliance requirements per NCQA, HEDIS, CMS, the State, Humana and others as required; and,
  • Monitors clinical program metrics and trends, working to align process improvements to preserve program integrity and clinical efficacy
  • Leads and participates on clinical process and program development workgroups and committees
  • Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures or governmental regulations
  • 3+ years’ experience in quality, compliance, NCQA accreditation, HEDIS, Special Needs Plans/ Medicare/ Medicaid experience
  • Must be able to travel as required by the business (up to 20% anticipated)
  • Must provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
  • Clinical experience with care management or case management background
  • Experience working with Department of Medical Assistance Services (DMAS)
11

Clinical Quality & Efficacy Manager Resume Examples & Samples

  • Has an understanding of concepts and methodologies including: Six Sigma, Agile, Lean, ISO 9001, Project Management and Crosby philosophy and tools
  • Experience with regulations and compliance regarding Data Security
  • Experience in the implementation of processes and procedures to maintain regulatory compliance
  • Experience with development and maintenance of metrics and metrics analysis and reporting
  • Credible, confident leader
  • Other—Strong organizational and communication skills, proven track record of working collaboratively in a team environment. Good leadership skills with the ability to manage projects of varying sizes, scopes, complexity. Strong problem solving ability, innovative and eager to explore new methods and technologies. Ability to prioritize and multi-task effectively; Business, financial and negotiation skills required. Proficient in Microsoft Office suite of applications
  • Professional certification in the areas of Quality Management, Lean, Six Sigma, Business Analysis, or Project Management
  • Ten or more years of experience in Quality Management, Quality Assurance and Continuous Improvement responsibility for highly complex, multi-site, multi-disciplined products, services, and systems
  • Experience implementing Quality Management Systems and understanding of ISO certified quality management systems and QMS principles
  • Change agent – ability to inform, educate and influence to overcome change resistance
  • Perseverance and dedication to principled behavior
  • Demonstrated ability to deliver sustainable benefits to the business
  • History of successfully influencing senior leaders with positive outcomes
12

Clinical Quality Program Consultant Resume Examples & Samples

  • Associates Degree or a minimum of five years relevant experience
  • 3+ years’ experience in quality, compliance, NCQA accreditation, HEDIS, Medicare/ Medicaid experience
  • Experience with Microsoft Office product suite; particularly MS Excel
  • Bachelor's Degree Preferred
  • Process or Project Management experience
13

Clinical Quality Consultant Resume Examples & Samples

  • End-to-end process design to meet Model of Care, NCQA and/or CMS requirements
  • Conduct research on appropriate educational materials for members
  • Develop creative solutions for various care management platforms
  • Assist internal and external stakeholders with design and deployment
  • Facilitate, participate, and communicate with cross-functional teams and work groups to provide subject matter expertise for program development or implementation
  • Develop and/or update process flows and program documents
  • Act as expert developer or contributor for collateral material detailing clinical programs; including policy, procedure, compliance, quality, core curriculum, and training documentation
  • Uphold the Model of Care regulatory compliance requirements for all regulatory bodies including NCQA, CMS, state regulatory agencies, and Humana
  • Monitors clinical program metrics and trends, to preserve program integrity and clinical efficacy
  • Read, analyze and interpret general business periodicals, professional journals, technical procedures or governmental regulations
  • Associates Degree or a minimum of 3+ years’ equivalent experience in quality, compliance, NCQA accreditation, HEDIS, Medicare/ Medicaid experience
  • Expert PC skills (including MS Word, Excel, and PowerPoint) required
  • Bachelor’s or Master’s Degree Preferred
  • Previous leadership experience beneficial
  • Familiarity with and an understanding of CMS or State regulatory requirements
14

Clinical Quality Consultant Resume Examples & Samples

  • Active RN license
  • Education: Bachelor's Degree
  • Prior clinical experience and expertise preferably in an acute care or provider setting practice
  • Knowledge and experience working with nationally established clinical quality guidelines and measurement sets such as HEDIS/NCQA or Joint Commission Standards for Accreditation
  • Strong analytical skills, able to research, manipulate and interpret data
  • Ability to measure, monitor, and track improvements in clinical care utilization
  • Ability to demonstrate problem solving skills
  • Valid driver’s license and dependable transportation necessary
  • Excellent public speaking skills
  • Education: Master’s Degree
  • Understanding of medical coding
15

Clinical Quality Program Admin Resume Examples & Samples

  • Performs assessments to identify gaps in the enterprises quality and technology assessment processes and initiates actions to correct these gaps
  • Assures accuracy and completeness of input provided to internal and external QI committees and timely implementation of appropriate interventions
  • Oversees the clinical quality improvement activities/projects to implement appropriate clinical interventions to improve the quality of care for Iowa Medicaid members
  • Assures QI activities are relevant to the targeted population. Assures compliance to Practice Guideline, Delegation and Continuity and Coordination of care Standards
  • Provides oversight to assure accurate and complete quantitative analysis of clinical data and presentation of results
  • May provide oversight to the Healthcare Effectiveness Data and Information Set (HEDIS) project team
16

Clinical Quality Audit Analyst Resume Examples & Samples

  • Requires an LPN/LVN; 2 years of experience in quality improvement, risk management and/or utilization review in a managed care setting; or any combination of education and experience, which would provide an equivalent background
  • Current unrestricted LPN/LVN license in applicable state(s) required
  • AS or BA/BS in Nursing preferred
17

Clinical Quality Consultant Resume Examples & Samples

  • Function independently, travel across assigned territory to meet with providers to discuss Optum tools and programs focused on improving the quality of care for Medicare Advantage Members
  • Execute applicable provider group programs for health plan
  • Educate providers on how to improve their Risk Adjustment Factor (RAF) scores, which measure their patients' health status
  • Establish positive, long-term, consultative relationships with physicians, medical groups, IPAs and hospitals
  • Develop comprehensive, provider-specific plans to increase their RAF performance and improve their coding specificity
  • Provide ongoing strategic recommendations, training and coaching to provider groups on program implementation and barrier resolution
  • Act as lead to pull necessary internal resources together in order to provide appropriate, effective provider education, coaching and consultation
  • Training will include Stars measures (HEDIS/CAHPS/HOS/med adherence), and Optum program administration, use of plan tools, reports and systems
  • Coordinate and lead Stars-specific JOC meetings with provider groups with regular frequency to drive continual process improvement and achieve goals
  • Provide reporting to health plan leadership on progress of overall performance, HQPAFs, gap closure, and use of virtual administrative resource
  • Facilitate/lead monthly or quarterly meetings, as required by plan leader, including report and material preparation
  • Provide suggestions and feedback to Optum and health plan
  • Work collaboratively with health plan market leads to make providers aware of Plan-sponsored initiatives designed to assist and empower members in closing gaps
  • 3 or more years of healthcare industry experience
  • Strong knowledge of Medicare ACO regulations
  • At least 2 years of previous exposure to HEDIS regulations
  • At least 2 years of experience presenting operational strategies to Primary Care Physicians
  • Must be willing to travel locally up to 50 - 75% to Vermont and parts of New Hampshire
  • Medical/clinical background – LPN, RN, or PA licensure helpful
  • A minimum of 1 year of Stars experience highly preferred
  • Healthcare Consulting experience
  • Previous experience in a Sales focused role
  • Previous experience traveling to Provider offices in the field
  • Strong financial analytical background within Medicare Advantage plans (Risk Adjustment/STARS Calculation models)
  • Exceptional analytical and data representation expertise; Advanced Excel, Outlook, and PowerPoint skills
  • Experience in managed care working with network and provider relations/contracting
  • Must have highly effective communication and presentation skills
  • Superior relationship building skills with clinical and non-clinical personnel
  • Advanced Microsoft Office skills
18

Clinical Quality Consultant Resume Examples & Samples

  • Responsible for developing and preparing documentation for NCQA and other accreditation surveys submissions
  • Works closely with regional quality staff, health plan staff, and internal business partners to build and document compliance with accreditation standards
  • Organizes and/or participates in readiness assessments in preparation for accreditation survey submissions
  • May interface with accreditation agencies and other regulatory and compliance bodies
  • Supports implementation of quality structure at regional and national levels
  • Undergraduate degree or 2 years of solid, documented experience in NCQA accreditation
  • 2 years experience solid knowledge of managed care and market regulatory requirements related to clinical
  • 2 years experience with NCQA or URAC accreditation in a managed care plan
  • Strong oral and written communication skills
  • Proficiency in Microsoft basic with Excel, Word Intermediate with Word and Powerpoint
  • CPHQ or other quality designation
  • Bachelors degree in healthcare related field
19

Clinical Quality Consultant, Accreditation Resume Examples & Samples

  • Serves as a technical advisor for accreditation compliance
  • Participates in the development and distribution of accreditation best practices
  • Develops policies and procedures that support accreditation activities
  • Bachelor’s degree in healthcare related field
  • 3 + years of solid, documented experience in NCQA accreditation
  • 2 years experience solid knowledge of managed care and market regulatory requirements related to clinical adherence
  • Proficiency in Microsoft with Excel, Word and PowerPoint
  • Access to high speed internet
  • Have a quiet location/workspace in your home that is separate from non-workspace areas and can be secured to maintain PHI or PI security in line with UnitedHealth Group policies and standards
  • Managed Medicaid experience
20

Clinical Quality Consultant Resume Examples & Samples

  • Function as Care Coach and Quality subject matter expert in consultation with MSO local teams
  • Hire, onboard and educate local MSO market Clinical and Quality teams
  • Experience in directly related HEDIS medical record review and/or Quality Improvement with experience in clinical data/chart reviews and providing clinical consultation and education to providers and provider staff
  • Experience in a managed care health services or related environment
  • MSO (Management Services Organization) experience
21

Clinical Quality Consultant Resume Examples & Samples

  • Selects 15 charts per day from a list of new members. The list will include members from high growth markets with consistent documentation improvement opportunities
  • Provide clinical review of the members' Skilled Nursing Facility and / or CareOne records to identify potential diagnoses for assessment and evaluation by the primary clinician
  • Complete SNF remote chart review when available, as well as a CareOne chart review of initial note when available
  • Identify and enter additional potential diagnoses to CareOne Diagnosis Tab, including the date of service (DOS) where the clinical evidence is found in the SNF chart, as reference for the primary provider to assess, document and code when appropriate at next clinical visit
  • Opens the member's attestation form and selects disagree for any suspect diagnoses which are not supported by clinical evidence in the chart
  • Enters chart review data on the excel sheet for each chart reviewed; ensures all fields are completed
  • Sends completed excel sheet to the Clinical Chart Review Manager on a regularly scheduled basis for accuracy review
  • Confers with the Clinical Chart Review Manager on monthly or bi - monthly basis to review audit results and accuracy rates
  • APRN or PA degree or equivalent Masters-level in nursing education and / or specialized training
  • 1+ years' direct clinical experience; Medicare Advantage experience a plus
  • Working knowledge of STAR / HEDIS and Risk - adjustment payment model
  • Up - to - date knowledge of latest coding and documentation requirements
  • Able to travel to Care Delivery Sites (25% travel)
  • Ability to analyze data / reports and make recommendations
  • Exceptional organizational, detail and accuracy skills
  • Ability to work in teams in a high matrix organization
  • Passion for patient care and dedication to success of internal customers
22

Clinical Quality & Operations Manager Resume Examples & Samples

  • Uses leadership tools to manage the Clinical pharmacists with side by sides, quality audits/reviews, consistent feedback using department report cards, and Medical Director feedback
  • Maintains skills and knowledge checklists for clinical pharmacists and clinical support technicians
  • Coordinates and oversees orientation and ongoing training of clinical pharmacists
  • Works with the Clinical Leaders to coordinate clinical pharmacy production workflows and ensure the timely completion of all clinical reviews and peer interventions
  • Ensures Clinical pharmacists are adhering to guidelines and coaches and trains staff accordingly
  • Assists with the coordination of the experiential training program for clinical pharmacy residents and/or pharmacy students when appropriate
  • Creates and maintains clinical quality and peer vendor related policies and procedures
  • Works with the Medical Director to provide updated content to the clinical guidance document
  • Performs Continuous Quality Improvement when necessary
  • Assists with management of the Peer Review Vendors
  • Provides subject matter expertise in client operational discussions for internal and external customers on as needed basis
  • Maintains patient privacy and confidentiality under requirements of federal and state law, including HIPAA, and in accordance with established policies
  • Holds Clinical Pharmacists to established performance expectations
  • 5+ years clinical experience including the assessment of complicated medication regimens and implementation of therapeutic interventions
  • 3+ years of prior Clinical leadership experience in a managed care or PBM setting
  • Sedentary physical activity, including sitting for long periods of time, requiring reaching, sifting, lifting, finger dexterity, grasping, feeling, repetitive motions, talking and hearing
  • Visual requirement is for close vision, distance, vision, peripheral vision and ability to adjust focus
  • 50% or more time is spent looking directly at a computer
  • May occasionally lift or move up to 25 lbs
23

Clinical Quality Coordinator Resume Examples & Samples

  • RN or other clinical training with 8 or more years of professional experience
  • Knowledge and experience in developing and/or managing quality measurement systems and in creating practical and effective practice workflow tools and supports
  • Experience in working directly with physicians in a coordinating role
  • Quality, Patient Safety, Population Health Management and/or Medical Managment credentials or experience a plus
  • Experience with project management or software implementation a plus
  • Health plan, Medical Record coding and/or Consulting experience a plus
  • Physician office based experience preferred
  • Strong problem solving skills with a wide degree of creativity
  • Able to prioritize work and manage time
  • Able to work flexible hours for early and late meetings
24

Clinical Quality Program Director Resume Examples & Samples

  • Requires a BS in health administration, nursing or a related clinical field; 5 years of health care quality or data analysis experience; or an equivalent combination of education and experience, which would provide an equivalent background
  • Current unrestricted license or certification in an applicable field (i.e. CPHQ) or MS in the health field (i.e. Nursing) preferred
  • Knowledge of state or assigned line of business needs and priority improvement areas required
  • Knowledge of Medicare and/or Medicaid is preferred. Knowledge of HEDIS and STARS is preferred
25

Associate Director of Clinical Quality Resume Examples & Samples

  • Drives day to day programs to assure member access to care and gaps in care closure
  • Aligns goals, strategy and tactics with the Regional Quality Director (RQD),State and Market CEO and CMO or other matrixed peers or leaders, when appropriate
  • Manages the market/state Quality Improvement Portfolio to drive and track data capture and collection, provider engagement and value based contracting, member engagement programs, clinical, and customer care touch points
  • Aligns and coordinates the work within their market/region and peers: HEDIS data collection, Data Analytics and Reporting, Accreditation, Member Surveys, Regulatory Adherence, product filings, and Member Activation and Engagement. Utilizing the expertise, standard process, and capabilities of these areas to enhance quality program performance of the plan
  • Fosters innovative problem solving and upholds principles of continuous quality improvement
  • Develops annual goals and objectives for the market and key metrics in conjunction & under the direction of the RQD, shared services teams and corporate goals & strategies to meet and exceed established program objectives
  • Monitors daily, weekly, monthly, quarterly, semi-annual and annual reports against goals to assess program success and alignment and to identify opportunities for improvement
  • BA/BS degree in healthcare related field; Clinical Registered Nurse preferred. Clinical Registered RN with AA degree is acceptable with commensurate demonstrated experience or outcomes specified below; advanced degree a plus
  • 3+ years of significant leadership or managerial experience e.g. management of process or discreet work stream is acceptable
  • 3+ years of experience in, and/or knowledge of, Clinical Quality and Quality Improvement processes, required. HEDIS/CAHPs and/or NCQA or other accreditation expertise preferred. (e.g. URAC) 3+ years working in managed care or a healthcare delivery system preferred
  • Superior verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
  • Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  • Understanding of market/state delivery system nuances including strengths and opportunities (e.g. ACOs, EMR, product or state requirement/s (e.g. Oxford Health Plan, state DOI or DCA requirements) – ability to review, analyze and articulate operations or necessary escalation/s for barriers to achieve goals
  • Prior experience managing a large/complex process or function (e.g. Clinical Coverage Review, Inpatient Management, Key Account or National Account clinical services, other specialized programs)
  • Open-minded and flexible in thought and tactics
  • Able to deal with complexity and ambiguity
  • Comfortable to reach out for clarification or direction, and take measured risks to achieve goals
  • Results Driven through influence and operational accountability
  • Able to build partnerships internally & externally to achieve results
  • Resilient, resourceful, optimistic and energetic
  • Ability to promote and live the values for United Culture (5 pillars)
26

Clinical Quality Data Analyst Resume Examples & Samples

  • Provide consistent and effective update to the Clinical Informatics Manager all assigned responsibilities
  • Assist the Clinical Informatics Manager with the training of clinical IT projects
  • Enters data into clinical systems to customize applications to reflect the policies of the clinical and IT department
  • Maintain user profiles in the clinical applications as needed. Monitors outside users to comply with HIPAA
  • Provide clinical application support as needed
  • Assist in the preparation of written reports regarding progress of clinical IT project implementations including but not limited to progress, barriers, etc
  • Assist in the implementation of all Company Clinical and Regulatory Strategic Goals, including new or revised company systems, policies and procedures and programs as it pertains to electronic health records applications
27

Clinical Quality Consultant Resume Examples & Samples

  • Positions in this function are responsible for direction and guidance on clinical Training quality improvement and management programs
  • Conducts clinical Training quality audits of materials; monitor accuracy of material publishing including: material updates, catalog, lists/libraries, archiving, index updates; work with support staff toward solutions when there are inaccuracies
  • Responsible for the reporting and analysis of Training quality and for the development of plans and programs to support continuous quality improvement
  • Analyzing data and identify risks
  • Presenting findings to leadership and department
  • Designing and maintaining training team SharePoint (SP) sites in order to develop solutions for manual processes, drive efficiencies, and improve/maintain user functionality
  • Maintaining current and detailed knowledge of Training SharePoint
  • Experience writing comprehensive documents
  • Advanced Excel skills (Pivot Tables, Macro’s)
  • Experience in design and maintenance of SharePoint
  • Experience in healthcare industry
  • 1 year experience healthcare data
  • RN license current and unrestricted
28

Clinical Quality Lead Resume Examples & Samples

  • Demonstrate a working understanding and familiarity of multiple EHRs preferably Cerner, Centricity and Allscripts and others as needed
  • Inform and educate data abstractors on changes in operational definitions, project deadlines, and regulatory changes related to work efforts serving as the lead
  • Troubleshoot for data abstractors and serve as knowledge base expert for assigned projects
  • Perform quality checks as assigned
  • Collects and accurately records data involving retrospective and/or concurrent chart reviews using a piloted audit tool
  • May create, test, and maintain various databases relating to data collected within project as needed
  • Prepares and cleans accurate base level reports
  • Troubleshoots software/hardware and network-based problems
  • Trains others in common software
  • Organizes large amounts of data/reports
  • Maintains data files in uniform way so that others can access files
  • Appropriately handles employees and patient questions regarding collection and analysis of data
  • Contacts responsible department manager when barriers to job performance occur
  • Communicates status of assigned projects as directed on a regular basis
  • Assists in the preparation of baseline and quarterly reports
  • Follows verbal or written job instructions
  • Assists in meeting and maintaining department goals and responsibilities
  • Attends project specific meetings
  • Actively participates at department meetings and communicates project specific updates
  • Actively reviews work flows in order to evaluate method of performing a task with the goal of increasing availability
  • Willingly performs others duties as assigned
  • Tracks, meets, and reports data submission deadlines as appropriate for work assignments
  • Review and delegate abstracted cases that may not meet performance standards to appropriate analyst for investigation and resolution
  • Serve as contact for outside agencies as directed by Director/Manager
  • Train and coordinate cross training for staff on projects as assigned
  • Works with Manager/Director to design and/or develop tools for department
  • Provides data entry and associated quality assurance and validation, including inter-rater reliability procedures, to insure data is accurate and ready for analysis
  • Demonstrates a proficient level with MS programs
  • Backs up targeted databases and other documents
  • Develops and pilots research audit tools, including reliability procedures
  • Demonstrates the ability to learn to recognize problems that might adversely influence work products
  • Maintains project specific key indicator(s) with quality and accuracy
  • Follows abstraction guidelines and stays up to date with project requirements
  • Coordinates with analysts to identify performance improvement opportunities and distribute information to appropriate parties
  • Maintains accurate and complete documentation for the projects responsible for
  • Integrates and communicates information from all dimensions of projects serving as lead on
  • Understands department finance goals and keeps department expenses to a minimum
  • Supports, adapts readily to, and assists in facilitating organizational and departmental change
  • Receives continuing education relevant to position
  • Remains current with knowledge of project(s) assigned
  • Continually explore ways of improving efficiency while maintaining high accuracy
29

Prin Clinical Quality Spec Resume Examples & Samples

  • 7+ years of experience (or 5+ years with a Master’s degree) directly supporting clinical research within a regulated environment, quality experience in a regulated environment
  • Experience with FDA and international regulations (pharmaceutical and/or device, e.g., 21 CFR 812, 11, 50, 54, 56, 803, 806, 820, ISO 13485, ISO 14155) OR experience in Quality System regulations
  • Knowledge of ISO 14971, AIMDD, MDD, CMDCAS/ CMDR, JPAL and other international regulatory agency requirements
  • Proficient computer skills and demonstrated competence to include word-processing, database applications, and spreadsheet in a network environment
  • Demonstration of self-motivation and leadership skills
  • Excellent written and oral communication skills and ability to interface professionally and diplomatically throughout all levels of the organization
  • Ability to manage time efficiently and multi-task
  • Ability to prioritize tasks using a risk based approach
  • Able to manage complex tasks
  • Strong interpersonal skills, ability to work with teams and be a self-initiator
30

Clinical Quality Auditor Resume Examples & Samples

  • Conducts systematic and periodic internal audits for DHPP delegated entities (HCP LLC and HCP AMG) in the areas of Quality, Utilization Management and Care Management to ensure compliance with regulatory and full service health plan contractual requirements
  • Issues Corrective Action Plans in response to findings from DHPP audits and present CAPS and progress to DHPP Medical Committee
  • Maintains a solid working knowledge of all full service health plan delegated responsibilities
  • Develops, revises and maintains all delegation oversight and internal audit tools and reporting systems to monitor regulatory compliance
  • Ensures policy and procedures adhere to mandated state and federal legislation and health plan directives
  • Assists in review and response to all audit reports including corrective action plans from full service health plans, CMS and DMHC in coordination with functional areas
  • Monitors and analyzes outcomes to ensure goals, objectives, outcomes and regulatory requirements are met
  • Collects and summarizes performance data, identifies opportunities for improvement, and presents findings and recommendations to all applicable Committees and Quality and Medical Management
  • Interfaces with clinical and administrative teammates company-wide to determine appropriate processes that comply with new law and regulations
  • Establishes and facilitates routine communication and feedback mechanisms for delegation oversight and internal audit findings to the Director of Delegation Oversight and Audit
  • Utilized findings and trends to make recommendations to improve policy and procedures and training
  • Maintains and tracks all full service health plan and internal audit results and follow-up activities
  • Works in coordination with the DHPP operations staff and functional areas on audit preparation for all full service health plans, DMHC and internal audits
  • Acts as a central resource with regards to regulatory requirements from participating regulatory agencies as well as health plan clinical review criteria and HMO benefits
  • Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPPA) standards
  • Computer literate: facile with Excel, Word and PowerPoint Presentations
  • Familiarity with CMS, Department of Managed Health Care (DMHC) (Knox Keene), California Department of Health Care Services (DHCS), and NCQA regulations, accreditation standards and guidelines
  • Thorough understanding of the RN scope of practice
  • Demonstrated success with cross functional communication and coordination
  • Ability to effectively interface with all levels of management
  • Strong leadership and interpersonal skills, including effective relationship building ability with external parties
  • Demonstrated ability to work with and understand physician organizations
31

Clinical Quality Coordinator Resume Examples & Samples

  • Performs timely and accurate abstraction and validation of clinical quality measures, as assigned (e.g., CMS/TJC Core Measures, Michigan Surgical Quality Collaborative (MSQC), Oncology Care Model (OCM)), utilizing clinical judgment and understanding of specifications and definitions related to appropriate patient populations and projects to meet requirements. Conducts regular review of data for quality assurance and to assess trends and identify areas for improvement and possible action
  • Synthesize and analyze large quantities of data and information to create succinct communications that influence decision-making and inform broad audiences. Develop and present both high-level and detailed reports, as needed, identifying opportunities for improvement and recommendations for next steps. Facilitates development of innovative approaches to visual metrics (e.g., dashboards) that assist teams with ongoing improvement
  • Provides clinical expertise and collaborates with multidisciplinary teams to recommend improvement opportunities, action plans, and implementation processes, including related education and follow-up in various department, unit, and/or project-specific meetings. Supports the Clinical Design Program by providing expertise in clinical quality measures and implementation of innovative care delivery models aligned with the triple aim and value-based care across the care continuum
  • Works closely with Quality Analytics and H.I.T.S. to implement electronic support of clinical data to reduce the burden of manual data abstraction, analysis, and reporting
  • A Bachelor's degree in nursing or health sciences and a minimum of 5 years of experience in analyzing and interpreting process, clinical outcomes and costs of care
  • Three to five years of clinical experience in a healthcare setting
  • Demonstrated knowledge regarding clinical quality, (e.g., best practice alerts, clinical guideline development, other clinical quality improvement)
  • Demonstrated ability to work with an interdisciplinary team, including clinicians
  • Experience with data management tools, computers, data abstraction, and analysis (e.g. Excel, SPSS, SAS, Tableau)
  • Demonstrated excellent written and verbal communication skills
  • Ability to perform in a self-directed manner within a team-focused framework
  • A Master's degree in nursing, health sciences business management, industrial engineering, or an equivalent combination of education and experience
  • Insight and knowledge regarding challenges and pressures facing providers
  • Experience with TJC and CMS mandated reporting requirements
  • Experience with the institutional Clinical Design, or similar, programs
  • Demonstrated knowledge of process improvement, lean principles, and associated tools and techniques
  • Knowledge of UMHS MiChart EMR system
  • Registered Nurse or other licensed healthcare professional
  • Underfill Statement
32

Medical Director of Clinical Quality Resume Examples & Samples

  • Current M.D. or D.O. degree with appropriate board certification or qualification
  • Master’s degree in Business or Medical Informatics highly desirable
  • 3+ years’ experience in implementation of a clinical quality program, PQRS, HEDIS, and GPRO submission strongly recommended
33

Clinical Quality Program Manager Resume Examples & Samples

  • Requires a BS in health administration, nursing, or a related clinical field
  • 4 years of health care quality or data analysis experience; or any combination of education and experience, which would provide an equivalent background
  • Current unrestricted license, certification in applicable field (i.e. CPHQ) and/or a MS in the health field (i.e. Nursing) is preferred
  • Requires Excellent PC skills (i.e. Word, Access, Excel)
  • Requires strong analytical skill set as well as strong verbal, written and interpersonal communication skills
  • Clinical quality background, auditor experience as well as NCQA or accreditation background required
  • HEDIS experience required
34

Clinical Quality Program Admin Resume Examples & Samples

  • BA/BS in health administration, nursing or related clinical field; 3 years of health care quality or data analysis experience; or any combination of education and experience, which would provide an equivalent background
  • Current unrestricted license or certification in applicable field preferred (i.e. LISW, LMHC, LMFT)
  • MS in the health field (i.e. nursing) preferred
  • Experience with medical charts and/or Behavioral Health charts preferred
  • Proficiency in Microsoft suite, SharePoint and SalesForce preferred
35

Clinical Quality Coordinator Resume Examples & Samples

  • Audits clinical work of other medical review staff for quality (monthly) and consistency (quarterly)
  • Provides feedback to medical review staff on results of audits
  • Involves Medical Director and department management staff as needed to resolve Reports audit results to Medical Review management monthly, includes trends or patterns noted in audit or analysis of findings
  • Works with Medical Review management to develop training materials based on audit findings and analysis
  • Presents training to staff as assigned by Medical Review management
  • Knowledgeable of sampling techniques to validate audit samples
  • Ability to maintain high quality work while meeting strict deadlines
  • Strong quality management experience including TQM or ISO
  • Excellent written and verbal communication skills including public speaking and human relations and ability to produce work free from typographical or spelling errors
  • Must be able to travel in order to provide training to other IntegriGuard sites
  • Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements
  • Registered nurse with license in good standing
  • Minimum of three years health care experience. Experience in Medicare medical review program required
  • Shows longevity in employment with one or more past employers
  • Valid nursing license required
  • Not currently sanctioned or excluded from any program operated by Federal or State Agencies including Medicare and Medicaid
36

Clinical Quality Reviewer Resume Examples & Samples

  • Perform Quality Assurance checks on final review work during and after the orientation period
  • Coordinate with, and assist, Project Managers in performing ongoing IQC for all Nurse Reviewers and Project Specialists per department procedures or more often if problems are identified
  • Facilitate the Physician IQC process and communicates/coordinates frequently with the Chief Medical Officer regarding indentified physician learning needs
  • Offers quality improvement suggestions on project protocols and processes; facilitates quality improvement plan in conjunction with Manager
  • Collaborate with Manager, Clinical Quality for identified quality issues
  • Work with Review Supervisor/Sr. Nurse Reviewer/Service Line Manager to facilitate quality improvement plan development and implementation as needed for both internal and external customers
  • Serve as a subject matter expert for contributions to the business proposal process
  • Assist with project data analysis, reporting and feedback
  • Demonstrated proficiency in medical record analysis and ICD-9-CM and CPT coding methodology or commercial utilization review guidelines
  • Advanced knowledge of medical codes, coding conventions and rules
  • Demonstrated experience in medical review, chart audits and quality improvement processes
  • Demonstrated experience with coding systems
  • Ability to demonstrate team processes and facilitate skills
  • Ability to apply healthcare data analysis to improve processes
  • Ability to work proficiently with Microsoft Word, Excel and Power Point
  • Ability to provide good customer service skills
  • Ability to medically review; chart audits, and quality improvement processes
  • Ability to analyze information and use logic and process to address work-related issues and problems
  • Ability to be careful and thorough about detail
  • Ability to function under pressure and deadline oriented project demands as well as manage multiple initiatives
  • Ability to multi-task and prioritize
  • Ability to organize well
  • Ability to perform oral presentations
  • Ability to work independently to meet objectives
  • Working knowledge of HIPAA privacy and Security rules
  • Active unrestricted RN license or RHIA, RHIT, RN, CCS, CPC or other licensed/accredited health care professional specific to scope of contract required
  • 3+ years clinical medical coding experience (1+ year clinical medical record auditing/validation experience required for coding only), preferably in a hospital setting
37

Clinical Quality Coordinator Resume Examples & Samples

  • Review draft protocols as assigned and return comments to the Project Manager or designee
  • Review relevant Standard Operating Procedures (SOPs) and introduce new SOPs as appropriate
  • Participates in client meetings, study initiation visits, and study update meetings as necessary
  • Ensure work carried out is in strict accordance with relevant protocols and Standard Operating Procedures, ensuring that the internationally required standards of Good Clinical Practice are met
  • Understands good documentation practices
  • Assists in continual improvement and development of source documents and processes
  • Develop, create, and gain approval for source documents for assigned studies
  • Understands usage of Microsoft Excel and Microsoft Word in regards to creation of time and event grids, screening source documents, on-study logs and templates
  • Assists in the QC of source documents against daily schedules and protocol
  • Ongoing daily review of the QC process for Study data
  • RDC query resolution
  • Conduct trainings in order to improve overall quality
  • Respond to Sponsor’s written data queries in a timely manner
  • Assists in error reporting
  • Transcribe study data into case report form
  • Work in conjunction with quality control and project manager to ensure that case report form completion timelines are met
  • Assist with on-time CRF completion and manages query process as required
  • Communicates deviations from protocol and SOPs to management
  • Typically 2-3 years of applicable experience
  • Knowledge of science or a scientific background is preferred
  • Ability to work to strict deadlines
38

Manager of Clinical Quality Resume Examples & Samples

  • Provide leadership to and accountable for performance of senior level professional staff
  • Liaise or manage supporting business segments external to the department
  • National Quality Management segments supporting the health plan
  • Manage all department clinical quality improvement function including accreditation, provider profiling, Quality of care / service initiatives and the Clinical Practice Consultant program
  • Supervision and oversight of credentialing functions necessary to support credentialing collaborative
  • Implementation and approval of the Quality Improvement Program and Work plan, as well as development and approval of the annual Quality Improvement Program Evaluation
  • Responsible for creation and delivery of regulator required reports and submissions, and ensuring compliance with all Quality Management requirements specified by regulator
  • Direct Quality initiatives to improve member care and meet state regulatory requirements (including all locally / nationally initiated Quality Improvement projects, state-mandated Performance Improvement Projects), and selection of new improvement projects after conducting analyses, literature review, and / or other quality reviews (e.g. barrier analyses, focus groups, surveys) to identify opportunities to improve member care and quality metrics
  • Participate in development, management and monitoring of national quality improvement projects
  • Conduct clinical quality audits
  • May be responsible for NCQA accreditation submission
  • Responsible for oversight of reporting and analysis of member care quality, provider and member satisfaction, and access and availability
  • Facilitates health plan quality committees, such as the Quality Management Committee and the Provider Affairs Subcommittee, and participates as appropriate national quality meetings
  • Conducts clinical quality audits and may also be responsible for NCQA requirements
  • Responsible for the reporting and analysis of member care quality and for the development of plans and programs to support continuous quality improvement using HEDIS and other tools
  • Missouri RN Licensure
  • Expertise with HEDIS
  • 3+ years of experience with demonstrated functional knowledge related to regulatory adherence of a quality management program (HEDIS, Accreditation, NCQA, Reporting, Committee Management)
  • 3+ years quality improvement and / or provider experience
  • 3+ years of demonstrated leadership and team development skills
  • Proficiency using a PC in a Windows environment, including Microsoft Word, Excel and PowerPoint
  • Certified Professional in Healthcare Quality (CPHQ) certification
  • Experience managing a virtual team
39

Stars / Hedis Clinical Quality Consultant Resume Examples & Samples

  • Develop market business plans to motivate providers to engage in improving Stars measures to be 4 STARS or higher
  • Provide analytical interpretation of Stars and HEDIS reporting, including executive summaries to plan and provider groups
  • Be the primary go to person for all STARS related activities within their assigned market(s) working within a matrix relationship which includes United Healthcare's Regional Vice President, Administrative Call Center Team, Health Plan Medical Directors, and other Health Plan and Optum team members to assure that all STARS activities are planned and executed
  • Assist OPTUM and UnitedHealthcare in development of training and analytical materials for Stars and HEDIS
  • Identify and assess decision makers and other key provider group personal with a focus on identifying barriers to achieving targeted outcomes. Focus communication and efforts accordingly
  • Develop solution-based, user friendly initiatives to support practice success
  • 1+ years of Stars experience, More than 3 highly preferred
  • 5+ years associated business experience with health care industry
  • Professional experience persuading changes in behavior
  • Knowledge base of clinical standards of care, preventive health, and Stars measures
  • Experience in managed care working with network and provider relations
  • Strong financial analytical background within Medicare Advantage plans (Risk Adjustment / STARS Calculation models)
  • Microsoft Office specialist with exceptional analytical and data representation expertise; Advanced Excel, Outlook, PowerPoint and MS Access skills
  • Strong problem - solving skills; the ability to analyze problems, draw relevant conclusions, and devise and implement an appropriate plan of action
  • Good business acumen, especially as it relates to Medicare
  • Medical/clinical background
  • Undergraduate degree preferred, post graduate degree
40

Clinical Quality Data Analyst Resume Examples & Samples

  • Bachelor’s degree in Computer Science, Management Information Systems, or equivalent job experience in the field
  • QA or Data Analysis experience
  • Working knowledge of SQL, Tableau, and related tools
  • Working knowledge of Microsoft Office and related tools
  • Experience with health care data is required
  • Strong analytical (detail-oriented), problem-solving, and organizational skills required
  • Strong customer service and verbal/written communication skills required
  • Experience with healthcare process/quality improvement or project management preferred
  • An ability to manage multiple tasks and assignments to meet deadlines is required
  • Experience analyzing and documenting requirements and processes
  • An ability to work effectively with all levels of team members is required, including both technical and non-technical staff, and both internal and external customers
  • Experience with EDI, HL7, X12, and other standardized transaction sets is a plus
41

Clinical Quality Lead Resume Examples & Samples

  • 3+ years of Quality Improvement experience
  • NYS Health Educator, Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Master Social Worker (LMSW), Licensed Clinical Social Worker (LCSW), and/or Foreign Medical Graduate (FMG)
  • Experience with Medical Record review working on HEDIS / QARR in a Managed Care setting
  • Previous experience with Coding and Chart Review
  • Previous experience in a Healthcare and/or Managed Care setting
  • Supervisory background
42

Clinical Quality Consultant Resume Examples & Samples

  • Establish positive, long - term, consultative relationships with physicians, medical groups, IPAs and hospitals
  • Develop comprehensive, provider - specific plans to increase their RAF performance and improve their coding specificity
  • Training will include Stars measures (HEDIS / CAHPS / HOS / med adherence), and Optum program administration, use of plan tools, reports and systems
  • Coordinate and lead Stars - specific JOC meetings with provider groups with regular frequency to drive continual process improvement and achieve goals
  • Facilitate / lead monthly or quarterly meetings, as required by plan leader, including report and material preparation
  • Work collaboratively with health plan market leads to make providers aware of Plan - sponsored initiatives designed to assist and empower members in closing gaps
  • Includes up to 75% travel within a 2 hour radius
  • 3+ years of healthcare industry experience
  • Previous experience with STARS and HEDIS regulations and strong knowledge of Medicare
  • Advanced MS Office Skills – specifically Excel – must have exceptional analytical and data representation expertise
  • Advanced Outlook, and PowerPoint skills
  • Medical / clinical background - LPN, RN, or PA licensure
  • Consulting experience or Project Management experience
  • Experience in managed care working with network and provider relations / contracting
  • Strong problem - solving skills
43

Clinical Quality Consultant Resume Examples & Samples

  • Perform data analysis, data management, and reporting
  • Perform program efficacy analyses, leveraging statistical analysis skills to evaluate the effectiveness of E&I Member Engagement programs (statistical analysis on data)
  • Serve as Program Manager/Project Lead managing and implementing E&I Member Engagement programs
  • Perform vendor management and oversight
  • Perform stakeholder engagement and communication
  • Monitor, track, and report program key performance indicator metrics
  • Manage program billing/invoicing processes
  • Facilitate and lead cross functional team meetings offering guidance and solutions
  • Bachelors degree in Business, Computer Science, Finance, Statistics, Health Administration, Public Health, or related field or equivalent experience
  • 4+ years of experience performing data analysis and making data-driven analytical decisions
  • 3+ years of experience in project management, leading projects from beginning to end
  • Be a team player willing to cover and learn other roles and functions
  • Proficient in Microsoft Power Point, Word, and Outlook
  • 2+ years of experience performing statistical analysis with experience working with statistical software (e.g., SPSS; Minitab)
  • Experience working with the Employer and Individual line of business
  • Proficient in SharePoint and Microsoft Visio
  • Process Improvement knowledge
  • Experience evaluating effectiveness of Clinical Quality programs related to HEDIS
  • Six Sigma knowledge
44

Lpn-clinical Quality Program Admin Resume Examples & Samples

  • Oversees the clinical quality improvement activities/projects to implement appropriate clinical interventions to improve the quality of care for members
  • Assures compliance with corporate QI work plans
  • Assures compliance to Practice Guideline, Delegation and Continuity and Coordination of care Standards
45

Clinical Quality Consultant Resume Examples & Samples

  • Develop market business plans to motivate providers to engage in improving STARS measures to be 4 STARS or higher
  • Provide analytical interpretation of STARS and HEDIS reporting, including executive summaries to plan and provider groups
  • Assist OPTUM and UnitedHealthcare in development of training and analytical materials for STARS and HEDIS
  • Lead Weekly, Monthly, Bi-monthly, Quarterly and / or Annual business Review meetings related to STAR activities which summarize provider group performance and market performance as requested or required by the Health Plan and the Director of Market Consultation
  • Analyze and evaluate provider group structure and characteristics, provider group/ provider office operations and personnel to identify the most effective approaches and strategies
  • Bachelor’s Degree or higher level of education
  • 5+ years of healthcare industry experience
  • Knowledge base of clinical standards of care, preventive health, and STARS measures
  • Medical / clinical background - LPN, RN, NP, PA, etc. licensure
  • Coding experience (ICD-9, ICD-10)
  • Consulting or Project Management experience
  • Strong problem solving abilities
46

Manager of Clinical Quality Resume Examples & Samples

  • Associates degree in nursing, health administration, health care, or business administration
  • Writing policies and procedures and other QI documentation
  • Experience in managing high priority projects that include data analysis, reporting and team management for data collection
  • 1+ years supervisor or management experience (overseeing non clinical and clinical staff)
  • Experience in quality, NCQA, HEDIS
  • Bachelors degree in health administration, health care, or business administration
  • Quality Improvement experience
  • Clinical Operations experience
47

Clinical Quality Coordinator Resume Examples & Samples

  • · RN required, BSN preferred
  • · Minimum of 2 years of experience working in the healthcare setting required; Population Health Management and/or Care Coordination experience preferred; Experience with practice management billing and medical coding
  • · Active RN Florida License required
48

Clinical Quality Consultant Resume Examples & Samples

  • *This is an office position in Richmond, Virginia**
  • Review results, conduct analyses (e.g., evaluate against goals/effectiveness of interventions over time), and prepare reports on findings for Performance / Quality Improvement Projects
  • Monitor, track and report program key performance indicator metrics
  • Evaluate current processes, compare to relevant standards or specifications and identify gaps in compliance or performance
  • Report results (e.g., quality improvement initiatives, audits) to committees, Board of Directors, external stakeholders, regulatory agencies, etc
  • BS / BA degree, advanced degree in clinical, public health, health education
  • 5+ years Managed Care experience in Medicaid, Medicare
  • 5+years’ experience with demonstrated functional knowledge of process improvement, quality improvement and change management
  • Advanced MS Office Skills - specifically Excel - exceptional analytical and data representation expertise
  • National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) knowledge
  • Medical / clinical background - RN, NP, PA, etc. Licensure
49

Clinical Quality Coordinator Resume Examples & Samples

  • Chart Abstraction and Audits: Develops and maintains tracking method for concurrent review of stroke patients to ensure compliance with all quality metrics. With great proficiency, performs accurate and timely data abstraction including but not limited to data for CMS, TJC, GWTG, QA initiatives, and the internal Stroke Log. Review all IV tPA and endovascular intervention cases to ensure protocols were followed; research details when problems arise, present case to Leadership. Maintains knowledge of measure specifications and data definitions necessary to complete this work. Leads inter-rater reliability sessions to ensure abstraction accuracy and success in external agency validation. Provides training to other team members and serves as a resource for data abstraction requirements, ensuring reliability and validity of data
  • Data Management: Works with data from many different clinical and administrative sources (internal and external to the UM-CSC) and has expertise to abstract, merge, manage, and prepare the data in the form of useful information to aid in analysis. Creation and maintenance of program specific patient satisfaction data as requirement by TJC, assessing and communicating trends for CSC leadership to determine correct interventions to reduce readmission rates and manage patient needs in correct level of care setting (e.g. outpatient clinic)
  • MiChart/HITS/Vendor Liaison: Collaborates with MiChart and HITS teams to optimize documentation efforts for clinicians, building of reports used for monitoring quality measurements and process improvement activities. Assists the team in creating crosswalks/uploads to external vendors utilized by the institution for reporting to external regulatory agencies. Troubleshoots any functionality issues with vendor products
  • Data Review and Quality Improvement Support: Thoroughly reviews clinical metric performance, assess for trends and underlying causes for deficiencies for escalation and review by the CSC Operations Director. Participates in a CSC quality, stroke arrival, and peer review meetings to support the data analytic portion of the process. Attends morbidity and mortality conferences for neurology, neurosurgery, neurointerventional radiology, and vascular surgery to ensure compliance with the monitoring and review of complication and mortality data as required for CSC programs. Monitor changes in laws, regulations and policies (specifically in the federal registrar that impact performance measurement and reimbursement) and assure compliance with reporting procedures and work flows
  • Reporting: Expertly produces all internal and external performance reports which include but are not limited to Stroke Core Measures, Stroke GWTG, Stroke Arrival, Peer Review, Comprehensive Stroke Measures, and CSC program specific elements that assist the CSC leadership in managing quality patient care to stroke patients as well as the program overall. Creation and maintenance of a real time dashboard for clinicians to utilize in increasing performance of our quality metrics for delivering interventions (IV tPA and endovascular therapies) to stroke patients. Provides reports for ad hoc meetings to address specific areas of deficiency. Maintains all databases for the CSC program and responds to requests by providers for data for research purposes. Provides training for report creation and serves as a resource for other team members, ensuring reports meet the standards of timely, discernable, reliable, meaningful, and actionable
  • On-Site Review: In collaboration with the CSC Operations Director, provide guidance and assistance in preparation for on-site surveys for TJC, as well as follow-up for areas of performance requiring attention identified during the survey. Aids the CSC Operations Director in the creation and distribution of tools and educational materials to improve understanding of and meet TJC requirements and expectations
  • Education: Provide education references to clinicians (physicians, nurses, APN/PA, etc.) related to clinical metric performance requirements within CSC
  • Process Improvement/Joint Commission Compliance: In collaboration with the CSC directors and other CSC team members, identifies areas of opportunities and conducts team meetings; recommend and evaluate processes to improve systems and patient care across the continuum of care; responsible for coordinating the efforts with team members for the development of performance improvement and action plans. Serves as subject matter expert for stroke center certification in response to inquiries from other departments such as emergency medicine, neurology, neurosurgery, vascular surgery, neurointerventional radiology, PT, OT, SLP, nursing units, etc
  • Provides support to CSC physician directors in design and delivery of care management of stroke patients: With physician leadership: Review and monitor care for the stroke population; review and revise provider ordersets, treatment guidelines, etc. and ensure alignment between the various protocols and ordersets that impact stroke patient care; reviews and maintains policies and procedures specific to the CSC
  • Participates in, coordinates and convenes CSC Standing & Ad Hoc Meetings: Chair or co-chair committees as assigned. Create agendas, produce meeting minutes, assign action items, and follow-up on tasks assigned
  • A minimum of a bachelor's degree in a recognized field which is directly related to the duties of this position, and a minimum of 5-8 years of experience in analyzing and interpreting process, clinical outcomes and cost of care
  • Demonstrated expertise in health information management: analyzing and interpreting data in a health care related field; providing education to clinicians; and lead role in process improvement activities
  • Experience with data management, analysis, and visualization tools such as Excel, SPSS, SAS, Tableau, etc.)
  • Experience in creating and disseminating discernable, reliable, meaningful, and actionable data; experience in establishing, implementing, and analyzing interventions to improve process and outcome quality measures
  • Broad understanding of health care and/or health policy terminology and the understanding of procedures and health care settings
  • Demonstrates critical thinking and analytical skills to understand root cause issues and how best to display information that is useful in creating opportunities for clinical improvement
  • Excellent organizational skills in setting priorities and balancing multiple priorities and demonstrated follow through bringing tasks to closure with acceptable outcomes
  • Excellent interpersonal, written and verbal communication skills with an emphasis on customer service
  • Ability to work independently with minimal supervision and maximum collaboration in a team environment
  • Ability to work with a diverse group of people in a diplomatic and effective manner with demonstrated problem solving and conflict resolution skills
  • Demonstrated commitment to enhancing work place culture, embracing diversity and a commitment to creating the ideal work environment for faculty and staff
  • In depth knowledge of University policies, rules and regulations, and professional knowledge is required
  • Background in cerebrovascular disease/stroke care or prior experience with processes and workflows in an inpatient setting is strongly desired
50

Clinical Quality Auditor Resume Examples & Samples

  • Performs various simple to moderately complex, comprehensive patient assessments, tests and procedures within the scope of practice of a Registered Nurse
  • Obtains, interprets, records and reports vital signs (temperature, pulse, respiration and blood pressure), height, weight, and other pertinent patient information to clinician
  • Prepares patient for examination and other procedures
  • Develops an appropriate nursing care plan
  • Implements a plan of care by performing nursing interventions and assisting with procedures
  • Instructs patient on procedural preparations
  • Administers medication and other therapeutic modalities within the scope of practice of a Registered Nurse
  • Collects, labels and transports various specimens to appropriate destinations
  • Performs patient and family teaching
  • Maintains clinical standards outlined in the clinical operations policies and procedures manual. Identifies deficiencies and recommends changes
  • Documents and maintains records of medical and nursing procedures
  • Coordinates with clinicians and ancillary departments to plan daily work assignments according to staff abilities, clinician and patient schedules, patient flow and procedures
  • Ensures adequate levels of supplies are maintained
  • Ensures that all equipment is maintained
  • Performs telephone screening and advice under the direction of clinician
  • Directs patients to appropriate levels of care and authorizes outside services
  • Notifies pharmacies of new prescriptions and authorizations of refills as ordered by clinician
  • Participates in educational programs to enhance nursing knowledge
  • Preferred: 5 or more years of experience
  • Basic Life Support for healthcare providers
  • Skilled in phlebotomy and I.V. therapy
51

Clinical Quality Consultant Resume Examples & Samples

  • Understanding of health related metrics
  • Excellent PC skills (including MS Word, Excel and PowerPoint) required
  • Understanding of Medicare Advantage initiatives (HEDIS, etc)
52

Clinical Quality Navigator Resume Examples & Samples

  • Gains clear understanding of criteria for compliance with clinical quality measures (numerator and denominator)
  • Enters patient demographics into collection tools
  • From measures identified in data collection tool, reviews chart for applicable documentation to support quality measures selected for each specialty
  • Gathers data from patient charts and record results via data collection tools
  • Data extraction of patients’ medical history from paper chart/Electronic Health Record consisting of but not limited to, past medical histories, medications, allergies, social history, immunizations, and clinical indicators into appropriate data collection tool
  • Ensures a high degree of accuracy of information entered with at least 90% accuracy
  • Works with Practice physicians and clinical staff to set abstraction appointments
  • Pulls charts according to the protocol and arranges for all necessary tools to conduct abstractions
  • Keeps director and quality nurse and other key members informed of results
  • Demonstrates knowledge and understanding of an EHR system and software functions
  • Works collaboratively with the management team for the Clinic(s) as a resource for quality outcomes
  • Works collaboratively with CIN quality nurse and care coordinator to assist in closing identified performance improvement activities and gaps in quality care
  • Complies with the Health Insurance Portability and accountability Act (HIPAA) and other state laws relating with Patient Privacy and/or Data Security shall be practiced on a daily basis. Must understand the use and disclosure of policies and procedures prior to disclosing any Private Health Information (PHI)
  • Ensures optimum operation of the department through good attendance history and flexibility with assigned shift. Is on time for scheduled shift
  • Must have reliable transportation to transport self to audit locations
  • Dresses in professional manner
53

Clinical Quality Coordinator Resume Examples & Samples

  • Promotes revenue enhancements to the ACO, LGH, and LGHP through maximizing quality, cost and utilization performance in Pay-For-Performance, Shared Savings, and other APMs to accelerate the initiated transition from Fee-For-Service to VBP
  • Utilizes clinical data and analytics to continually evaluate patient care outcomes, identify gaps in care and expedient methods for closure, and assignment of ACO attributed high/rising risk patients to appropriate Care Management resources, e.g. Ambulatory Chronic Care Team (ACCT), LGH Care Connections, Pharmacy etc
  • Creates an environment of continuous quality improvement, implements action plans, and identifies resources to address identified gaps in care
  • Collaborates with and supports nursing staff, physicians, operations, risk management, information services and other members of the health care team to achieve patient outcomes by developing, implementing, and measuring effectiveness of clinical practice guidelines across the ACO’s CIN
  • Serves as a role model and provides clinical consultation and education for the members of the multidisciplinary health care team in LGHP to define best practice standards, optimal clinical staff support, and resource availability to support physicians for success in a performance based healthcare environment. This position would collaborate with the Care Transformation team and in particular collaboratively work with ACO Analysts and the CT clinical educator to spread quality improvement opportunities and best practices
  • Facilitates the formation of collaborative clinical improvement teams and being paired with an operational leader(s) co-leads the efforts in meeting the goals of the team(s) including, with the business support of ACO Analysts and other supporting roles, variance analysis, aggregate trend analysis, and recommendations for changes in practice to improve outcomes and maximize value based revenue for ACO, LGH, and LGHP
  • Collaborates with practice teams, Information Services and health system resources to develop systems and processes to support improved outcomes especially related to external quality incentive program requirements vital to ACO, LGH, and LGHP
54

Clinical Quality Consultant Resume Examples & Samples

  • Works closely with Account Management teams to ensure client satisfaction with accreditation support received from UnitedHealthcare
  • Participates in regular meetings with Account Management and external clients as needed. Build positive relationships with external clients
  • Responsible for developing and preparing documentation for external clients’ accreditation surveys. This includes AAAHC, URAC, and NCQA accreditations
  • Prepares and submits ongoing reporting to satisfy client oversight requirements
  • Works closely with internal business partners to build and document compliance with accreditation standards utilized by external clients
  • Complete reports that provide analysis of data related to key quality and accreditation projects
  • Organizes and/or participates in readiness assessments in preparation for clients’ accreditation survey submissions
  • Undergraduate degree or 2 years of solid, documented experience in successfully preparing and submitting AAAHC, URAC, NCQA or other healthcare accreditation surveys
  • 2 years of experience and solid knowledge of managed care and market regulatory requirements related to health plan quality
  • 2 years of experience with AAAHC, URAC or NCQA accreditation standards in a managed care plan
  • Proficiency in Microsoft basic with Excel or Access, Word Intermediate with Word and PowerPoint
  • Commitment to achieving high levels of satisfaction with external customers
  • Experience with AAAHC accreditation standards
  • CPHQ or other quality designation preferred
55

Performance Improvement Analyst Clinical Quality Resume Examples & Samples

  • Preferred two (2) to three (3) years experience in performance improvement
  • Preferred one (1) to two (2) years experience required by the specific department
  • Current FL RN License
56

Clinical Quality Asst-medical Assistant Required Resume Examples & Samples

  • Outreach to external physician offices to obtain copies of consult notes and reports for patients who had preventive healthcare screens and clinical measures completed at outside facilities
  • Communicate regularly with interdisciplinary team members to coordinate/update a patient’s care
  • Explain the importance of preventive health screens and clinical measures to patients and families
  • Maintain accurate tracking log of patients who have been outreached and status of their preventive health screens and clinical measures
  • Participate in various quality driven initiatives within USMD and collaborate together to achieve high level patient outcomes
  • Submit data to external agencies as directed by manager
57

Clinical Quality Coordinator Resume Examples & Samples

  • Reporting: Expertly produces all internal and external performance reports which include but are not limited to Stroke Core Measures, Stroke GWTG, Stroke Arrival, Peer Review, Comprehensive Stroke Measures, and CSC program specific elements that assist the CSC leadership in managing quality patient care to stroke patients as well as the program overall. Creation and maintenance of a real time dashboard for clinicians to utilize in increasing performance of our quality metrics for delivering interventions (IV tPA and endovascular therapies) to stroke patients. Provides reports for ad hoc meetings to address specific areas of deficiency. Maintains all databases for the CSC program and responds to requests by providers for data for research purposes. Provides training for report creation and serves as a resource for other team members, ensuring reports meet the standards of timely, discernible, reliable, meaningful, and actionable
  • Senior leve will require a minimum of a bachelor's degree in a recognized field which is directly related to the duties of this position, and a minimum of 5-8 years of experience in analyzing and interpreting process, clinical outcomes and cost of care
  • Intermediate level will require a minimum of a bachelor's degree in a recognized field which is directly related to the duties of this position, and a minimum of 3 years of experience in analyzing and interpreting process, clinical outcomes and cost of care
  • Experience in creating and disseminating discernible, reliable, meaningful, and actionable data; experience in establishing, implementing, and analyzing interventions to improve process and outcome quality measures
  • Experience with The Joint Commission Primary and/or Comprehensive Stroke Center certification (Disease Specific Care Certification)
  • Experience with Stroke Core Measures and/or Stroke Get with the Guidelines abstraction and reporting
  • Experience in clinical process improvement
  • Experience in clinical quality, safety and management work
  • Lean or Six Sigma methodology experience
  • Ability to simultaneously oversee multiple projects
  • Knowledge of Epic electronic medical record system
58

Clinical Quality Performance Management Associate Resume Examples & Samples

  • 50% Customer Success
  • Coordinate and Implement on multiple quality performance management programs that will produce higher ROI for clients (ie what is success for our clients), providing deliverables within defined timelines
  • Analyzing quality performance data (using excel, Business Intelligence tools, etc) across the network identifying trends and opportunities in order to formulate hypotheses and bring recommendations to your manager/team
  • Report on specific value based care program activities, industry insights, and metrics
  • Help operationalize measurement of success, ensure availability of data and manage cross-client analysis to monitor success against defined metrics
  • 30% Project Management
  • Manage and see to resolution client and internal team questions and support cases to ensure timely and accurate responses as well as success of quality metrics
  • Uncovering user stories and digging deeper to understand true customer goals/needs/job to be done
  • Respond to CRM cases in a timely manner with high degree of customer service
  • Identify product gaps and "bugs"; assist in quantifying impact of internally reported or client-reported issues
  • Execute rigorous testing methodologies to ensure we are delivering the correct quality content to clients
  • 20% Cross-Functional Support & Relationship building
  • Execute on cross-functional projects as requested
  • Participate in fostering athenahealth and QP Team culture in order to ensure successful team goal achievement
  • Build relationships across internal teams (e.g., product, marketing, client engagement, client support teams) to maximize efficient project execution or support efforts
  • BA or BS degree required; additional education a plus
  • Strong computer literacy including Excel and PowerPoint; SQL and HTML literacy preferred
  • Understanding of (or desire and ability to learn) medical terminology, EHRs, and value based care landscape
  • Flexibility and willingness to take on new tasks and challenges
  • Demonstrated ability to identify issues, hypothesize solutions, and see them through to completion
  • Experience managing one's own time and being held accountable for delivering work within pre-determined timelines
  • Experience working with data to define a problem and recommend solutions
  • Proven ability to become a subject matter expert, synthesize information and present to a group
  • Experience in additional support tools (e.g., Salesforce, SQL, Jira) a plus
  • Ability to communicate effectively with peers and clients
  • Learns quickly and will try anything to find a solution
  • Uses rigorous logic and testing methodologies to understand root causes of problems
  • Gathers input broadly and can develop solutions that have the right focus and scope
  • Self-manages own time and deliverables on any given project
  • Systematic and understands how to do more with less
  • Excellent communicator with a strong sense of personal integrity
  • Willing and excited to work in a fast-paced and rapidly expanding company
  • Comfortable working with clients with a professional attitude to deliver results
  • Goal-driven and passionate about delivery high quality work
  • Ability to understand client perspectives and to work effectively with client-facing organizations
  • Creative thinker who can implement innovative solutions
59

Field VP Clinical Quality Resume Examples & Samples

  • Defines and executes quality strategy and initiatives on an Associate level providing the pertinent oversight and direction for the administration of clinical quality management policies, standards and processes developing long and short term goals and objectives related to improvement of clinical outcomes and patient safety and taking the appropriate steps to achieve the goals
  • Oversees, directs, and monitors the Associate implementation and integration of the FMCNA Quality Enhancement and Management Program (QEMP) into the facility standard operating procedures
  • Oversees the development, implementation and evaluation of quality plans and programs to reduce operational and safety risk within the FMS Associate
  • Drives the development of appropriate Quality policies and procedures to ensure superior patient outcomes and compliance with all pertinent regulatory requirements collaborating with peers in other Associates to ensure consistency
  • Collaborates with the appropriate corporate stakeholders regarding the communication and training of personnel on FMS Clinical Quality policies and procedures
  • Contributes to the development and revision of quality tools for use in the facilities
  • Ensures and facilitates a frequent evaluation and audit process to determine effectiveness of Quality related programs and initiatives, and to identify improvements to result in achievement of company and Associate quality goals
  • Ensures conclusions from data collection and auditing activities are incorporated in the education and training programs Supports the building of collaborative relationships with key Medical Directors and Medical Advisory Board Members to promote quality outcomes, providing guidance regarding addressing barriers to improvement and promoting evidenced-based and better clinical practices. Acts as the Associate liaison with the Corporate Medical Office and Clinical Services department
  • Ensures the appropriate communications between Associate Quality team staff, Corporate Quality and Clinical Services staff and the relevant Operations management in the Associates. May prepare written communications for distribution within the Associate regarding various initiatives and projects collaborating with the stakeholders
  • Reviews and analyzes information and data pertaining to clinical quality structure, process and outcomes including the quality activity and facility risk assessments and mitigation summary reports. Provides updates, reports and presentations on Associate Quality Improvement activities, outcomes, and issues to Associate executive team
  • Drives and oversees the development of facility-specific and regional quality goals and action plans
  • Collaborates with the Associate Vice President of Education, Regional Vice President, and FMS Clinical Services Department in the development of training programs and processes to ensure the implementation and incorporation of FMS quality standards and the practice of Continuous Quality Improvement in facility standard procedures and that all ESRD regulatory and legal requirements are met
  • Ensures the appropriate provision of assistance in the addressing of and acting on any adverse events and action thresholds
  • Hires Department Directors of Quality for the Associate according to FMS selection standards, and provides input on the selection of regional FMS quality personnel
  • Provides continual informal feedback to direct reports and formal feedback in the form of the annual performance review. Manages the staffing of the Associate Quality department through a responsible hiring and firing process. Provides oversight regarding disciplinary actions working with Human Resources as appropriate
  • Responsible for development of an efficient and prudent annual Department budget and meeting or exceeding budget goals
  • Ensures that Department goals are aligned with Corporate, Associate and Regional goals
  • Provides guidance and expertise regarding issues related to quality management, including clinical, technical, and operations issues and supports action plans to correct clinics below threshold performance
  • Supports Associate, Regional, Area and facility-specific business plans with respect to Quality and Quality related initiatives
  • Maintains current knowledge of community and regional healthcare markets including industry issues that impact the business
  • Collaborates with internal and external counsel to resolve legal and litigation issues with the goal of diminishing expenses
  • At least 8 to 10 years experience in dialysis, preferably within field operations with at least 4 years at the director level
  • Demonstrated quality management and improvement experience, adult teaching experience, and project management experience
60

Dir-clinical Quality Measures Resume Examples & Samples

  • BA/BS in relevant field
  • 5 - 7 years healthcare experience
  • Electronic health record experience
  • Knowledge of the domain of clinical quality data and outcomes
  • Analytical, resourceful, and possess excellent problem-solving skills
  • Ability to work as a team player with excellent communication skills
61

Ambulatory Clinical Quality Coordinator Resume Examples & Samples

  • Responsible for learning/maintaining current knowledge of quality program requirements
  • Participates in corporate-wide Ambulatory performance improvement initiatives. Assists CHS network physicians and staff with understanding and reporting of performance improvement activities
  • Responsible for reviewing medical records, and abstracting clinical data elements for quality measures according to published criteria
  • NYS licensed RN, NP, or Physician Assistant
  • Bachelors degree required (associated degree will be considered based on experience with position requirements); Masters degree preferred
  • Six Sigma Green Belt or LEAN certification a plus
  • Must have knowledge of practitioner care principles, procedures, and practices
  • Demonstrates understanding of Hospital and Ambulatory/Practice-Based clinical environments and workflows
  • Experience in working with an Electronic Health Record
  • Proficiency in database, spreadsheet, and word processing software applications essential. Microsoft Office proficiency required
  • Familiar with Six Sigma, PDCA and/or other performance improvement methodologies
  • Demonstrates the ability to effectively communicate with all levels of hospital and practice-based staff in a verbal and written manner
  • Possesses keen analytical skills and demonstrates the ability to be very organized
  • Effectively plan projects, workflow activities, and assignments
  • Minimum of 3-5 years clinical experience required
  • Performance Improvement and Quality Management experience preferred
  • Prior experience in clinical quality measure data abstraction preferred
  • Some travel to other CHS network facilities/practices
62

Clinical Quality & Service Manager Resume Examples & Samples

  • Develops and maintains strong relationships, using effective interpersonal and communication skills, with affiliate providers/staff, employer groups, CPMG and health plan leaders and colleagues to positively impact the growth of membership, KP services and programs
  • Uses project management methodologies to implement effective and efficient programs and conduct program evaluation
  • Uses process improvement and organizational change methodologies to support network providers in program implementation and clinical quality improvement
  • Coordinates Kaiser Permanente programs and services related to value based contracting, care coordination, disease management, prevention services and patient engagement; provides clinical decision support services
  • Manages P4V agreements with network providers; acts as primary point-of-contact to these providers, coordinating responses to provider concerns with a variety of internal departments
  • Identifies and develops data collection resources to support the assessment, monitoring, and evaluation of program activity; conducts medical records audits, as necessary
  • Facilitates PCP practice transformation by providing initial and ongoing clinical and operational workflow consulting to optimize clinical and financial success
  • Conducts high-level data analysis and presentation to inform stakeholders and support decision-making
  • Manages the external sources of data to assure timely, accurate, and complete data per specifications
  • Acts as an educational resource for health plan staff, affiliate physician/staff and employer groups to address gaps in knowledge related to HEDIS, quality improvement strategies, disease management, case and care coordination, transition management, and other clinical outcomes
  • Works independently under broad direction and leads/participates in team initiatives
  • Five (5) years of experience in project management and/or quality improvement in a health care environment
  • Demonstrated experience in analytical, statistical, and auditing techniques, data collection systems, survey methodology, and report design
  • Experience with electronic health records (EHRs)
  • Business, clinical or health plan experience with network model of care delivery
  • Experience with implementing change using Lean, Six Sigma, or other process improvement methodologies
  • Subject matter expertise with HEDIS measures and/or clinical quality measures
  • Master's degree in health care administration or business preferred
  • 50% of the position is managing the resource team staff, the sleep team scheduling staff, and collaborating with service departments in D/B for improved member service. 50% of the position will focus on SoCO quality including pay for value, SNF quality, ASC quality, and MOB quality
63

Senior Analyst, Clinical & Quality Solutions Resume Examples & Samples

  • Evaluates large sets of data and draws insights to formulate recommendations
  • Collaborates with Actuarial and Operations teams to develop cost models, revenue models and ultimately calculates return on investment
  • Responsible for supporting new product development and growth of the Stars business
  • Provides sales support as a Stars analytical SME
  • Work with the leadership team to execute on the Stars business roadmap
  • Supports client engagement from pre-sales / sales through transition to implementation
  • Develop service offerings and add-on components to increase value of the solution
  • Innovate and stay abreast of industry trends
  • Contribute to advancing innovation and improved execution of the client experience
  • Utilize thorough understanding of Stars measure analytics to perform investigative research
  • Evaluate and prioritize recommendations for Stars / Quality improvement
  • 5+ years’ experience in an analyst role within a health plan Quality / Stars department
  • Able to manage and prioritize large projects with great visibility
  • 3+ years of Star experience, performing a wide range of functions with strong focus on data analysis and interpretation
  • Advanced MS Office Skills – specifically Excel – must have exceptional analytical and data expertise
  • Have expertise in health plan operations, especially around Stars (e.g. IRE, CAHPS, etc.)
  • Intermediate level understanding of Quality Measurement and Improvement
  • Previous experience with Stars and HEDIS programs
  • Knowledge of Medicare and / or Medicaid
64

Manager of Clinical Quality Performance Resume Examples & Samples

  • 30% Quality Product Performance Management
  • Recommend and implement clinical performance improvement opportunities based on data analysis results
  • Contribute to development and implementation of client best practices for one area of ownership (with goal of improving overall client performance), examples include
  • BA or BS degree required; master's Degree (Health Informatics, MBA, MPH, etc.) preferred
  • 5-6 years minimum experience or prior roles with progressive responsibility
  • Demonstrated past experience in delivering team success via data-driven metrics & reporting
  • Experience working with large datasets; SQL preferred
  • Strong problem solving, analytical and quantitative skills
  • Understanding of healthcare/ Health IT and in defining opportunities to improve healthcare preferred
  • Experience with mentoring and/or direct team management
  • Demonstrated ability to command attention through presentations and distill complex ideas into coherent and easy-to-understand language
  • Aligns people, project and processes to achieve goals
  • Sets high standards, is resourceful in achieving those aims, and provides frequent feedback loops
  • Ability to be flexible and change gears and re-organize teams as needed
  • Knows and communicates priorities effectively
  • Uses data to define issues and business problems and seeks out stakeholder input as needed
  • Groups problems into themes to inform future direction of product/team
  • Effectively plans projects, anticipates problems, and finds appropriate mitigation steps
  • Well-organized and can start to communicate a future vision for functions/processes on the team
  • Effectively delegates to team members and clearly state expectations
  • Is comfortable moving between the player and coach on the team, at times leading and at other times executing on tasks
  • Passion for improving healthcare, with empathy for the user of our products and services
  • Excited to work with others through change
  • Proven track record of delivering measurable business results
  • Proven ability to independently manage many changing tasks simultaneously
  • Translate mission, vision and business objectives into stories that interest employees and bring the vision and core values to life
65

VP, R&D / Clinical Quality Resume Examples & Samples

  • Bachelor's degree or greater in science, pharmacy, or manufacturing.​
  • Fifteen to twenty years of experience with increasing levels of responsibility within the R&D/Clinical area. This includes hands on experience with managing regulatory inspections (FDA, MHRA, etc.) within the Clinical and R&D areas
  • Twelve to fifteen years of management I leadership development experience
  • Extensive working knowledge of US and Worldwide GxP regulations and experience with regulatory compliance inspections
  • Global Compliance/QA experience at manufacturing sites outside the US on an ongoing basis. Extensive experience with GxP systems approaches and implementation of such systems
  • Demonstrated ability to effectively lead professional staff; proven ability to work in a collaborative team environment across multiple technical functions
  • Demonstrated ability to effectively interact with both global functional areas (GxP) and manufacturing sites (GMP) and third party vendors
  • Strong project management and organizational skills
  • Excellent interpersonal skills (including, listening, writing, negotiation, facilitation, attention to detail and presentation skills)
  • Advanced degree (Ph.D.) in science, pharmacy or engineering preferred​
  • Compliance/QA experience at a pharmaceutical I bio-pharmaceutical with specific antibody and vaccine experience preferred
66

Clinical Quality Documentation Specialist Resume Examples & Samples

  • Bachelor of Science (BS) Degree
  • 1+ years of pharmaceutical industry experience associated with preferred clinical (GCP) study / good documentation practice exposure. Working knowledge of applicable GCP regulations and guidelines
  • Good documentation practice (GDP) experience/training
  • Working knowledge of applicable GCP and/or Regulatory Affairs regulations and guidelines
  • Attention to detail and analytical mindedness
  • Experience working in global and multidisciplinary environments
  • Must be IT systems literate (MS Word, Excel, & Power Point) and be familiar with audit tracking systems (e.g., Trackwise) and regulatory submission management submissions
  • Assist in conducting document reviews in support of internal IBM (independent business monitoring) assessments
  • Support external regulatory inspections and internal corporate audits
  • Compile corrective and preventative action (CAPA) evidences
  • Assist in Trackwise and CARISMA record management responsibilities
  • Prepare (access) and plan (prioritize, schedule) for clinical study document reviews
  • Conduct reviews of clinical study documents
  • Report (document) results of clinical study document reviews
  • Consult with Clinical Development Quality Assurance (CDQA) subject matter experts (SMEs) and document publishers to remediate non-compliances to good documentation practices
  • File and archive clinical study document reviews in audit management system (AMS)
67

Clinical Quality Audit Analyst Senior Resume Examples & Samples

  • Provides recommendations for quality improvement studies including selection of valid and reliable indicators and coordinates monitoring and evaluation activities upon select implementation
  • Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance with Company procedures; defines opportunities for improvement through trend analysis and communicates information appropriately
  • Assist in implementation and monitoring of quality studies including, but not limited to the development and implementation of preventive health and chronic disease outcomes improvement interventions such as newsletter article, member education and outreach interventions, provider education and outreach interventions, medical record review, focus studies and surveys
  • Perform monthly, quarterly, annual and ad hoc medial record reviews such as HEDIS
  • Requires 2 years experience in quality improvement, risk management and/or utilization review in a managed care setting
  • Knowledge of local and national quality management and regulatory standards, including NCQA and HEDIS reporting
  • Current unrestricted RN license in applicable state(s) required, with CPHQ preferred
  • BA/BS degree in Nursing preferred
68

Senior Consultant, Clinical Quality Resume Examples & Samples

  • Provide support and guidance on clinical quality operations, quality improvement initiatives and quality management programs
  • Serve as a subject matter expert for HEDIS, CAHPS, Medicare Star Ratings, and other state specific regulatory programs such as CA IHA P4P
  • Provide project management support for consulting engagements
  • Provide consulting support for client engagements
  • Assist in the development of written proposals and power point decks to support business development efforts
  • Support root cause analysis and develop targeted interventions designed to improve clinical quality outcomes
  • Assist with the development and execution of strategic plans to support targeted quality improvement interventions for specific HEDIS measures
  • Support the development, launch and execution of new consulting offerings and technical tools managed by the clinical quality consulting practice group
  • Write programs in SAS or SQL to support consulting engagement deliverables
  • Perform in-person presentations for clients related to HEDIS data
  • 5+ years of experience in HEDIS data operations
  • Intermediate to Advanced Knowledge of SQL
  • 3+ years of Database experience with Oracle, Microsoft, and/or Teradata
  • 3+ years of HEDIS related report development experience in SAS or SQL
  • 3+ years of HEDIS management experience
  • 3+ years of Medicare Star Rating experience
  • Base SAS Programmer or Advanced SAS Programmer Certification
  • 3+ year of experience with standard and non-standard supplemental data
69

Lead Clinical Quality Informatics Resume Examples & Samples

  • Perform feasibility assessments, and risk assessments, and provide recommendations
  • Provide briefings to senior MITRE and Sponsor staff-both technical and lay
  • Ability to bridge disciplines(e.g. biology and information technology)
  • Previous demonstrable experience within HHS or with HHS clients, preferred
70

Clinical Quality Associate Resume Examples & Samples

  • Becoming a subject matter expert on CMS Quality Performance Programs, including MIPS and APM, and help organizational success in these areas
  • Researching, designing, and implementing strategies to support client performance in the MIPS Improvement Activities (IA) performance category
  • Developing a detailed understanding of the PCMH/PCSP care delivery model and provide guidance to clients wishing to pursue Medical Home Recognition
  • Managing client questions, escalations and requests regarding PCMH, PCSP, and IA programs and becoming a trusted advisor to our clients and other internal teams
  • Evaluating the effectiveness of athena’s services for PCMH recognition and creating strategies to drive PCMH adoption and recognition
  • Working cross-functional with other athena teams to ensure we are delivering the best services for our clients
  • Developing and monitoring clinical performance team reporting tools and metrics
  • Executing multiple projects at once and producing deliverables within defined timelines
  • Identifying and implement performance improvement opportunities
  • Contributing to development of team processes and reporting
  • Becoming an active participant in athenahealth’s teaching and learning culture
  • BA Degree in a health care field; MPH, MBA, or other advanced degree a strong plus
  • Medical Informatics, RN/NP/PA, MPH, MBA, MHA and additional education or certifications such as the PCMH Content Expert Certification are a bonus
  • Knowledgeable in health technology, health insurance guidelines and regulatory standards, as they relate to the physician practice setting
  • Strong critical thinking and problem-solving skills
  • Excellent organizational skills, analytical ability, and strong attention to detail
  • Proven ability to work both independently on projects and as part of the larger team
  • Ability to identify issues, hypothesize solutions, and deliver results
  • Ability to instruct others, especially peers and clients to explain athena process workflow concepts using clear communication
  • Professional attitude – comfortable working in a corporate setting populated by diverse types of people and able to maintain poise and a sense of humor in stressful situations
  • Understanding of (or desire and ability to learn) medical terminology and EMRs
  • Understanding of medical terminology and ability to research specialty-specific practices
  • Strong computer literacy including MS-Word, Excel and PowerPoint; SQL and HTML preferred
71

Clinical Quality Auditor Resume Examples & Samples

  • Support EmblemHealth’s Quality program of managing member health outcomes and raising quality scores by conducting targeted chart review with the purpose of enhancing quality scores through ongoing Medical Record Review abstraction exchanging data with groups, vendors and internal EH departments to promote appropriate documentation, collect, abstract and record data
  • Partner with colleagues in addressing results of medical record audits and academic detailing with physicians, staff, and pharmacists, vendors/delegates, etc through site visits, webinars, and telephonic outreaches to address compliance with Clinical Practice guidelines, Preventive Health guidelines, Quality improvement activities, HEDIS/QARR to improve the delivery of quality health care to EmblemHealth members. 80%
  • Conduct targeted medical record review audits for specified provider groups and vendors/delegates to ensure members are receiving appropriate medical care, identify areas for provider education, academic detailing, and assess for trends in records reviewed. Audits will be conducted, summarized and reported back to corresponding product team or delivery system workgroup to act on identified issues. This also entails addressing member receipt of care through vendors/delegates and member outreach as appropriate
  • Maintain up-to-date knowledge and understanding of HEDIS/QARR/Star measure technical specifications and provide any clinical support related to assigned measures. Make recommendations on initiatives and outreaches based on knowledge of the specific clinical criteria of the measure
  • 20%
  • Strong analytical, problem-solving, and independent decision-making skills
  • Strong attention to detail with excellent written and verbal communication skills
  • Ability to work in fast-paced and dynamic environment with minimal supervision and direction and to constantly redefine responsibilities to meet business needs. Works with urgency
  • Excellent assessment and clinical skills
  • Computer literacy and experience with word processing, spreadsheets, database programs and good typing skills
  • Knowledge, understanding, and accurate interpretation of product line related specifications, methodologies, and processes
  • Ability to be flexible and remain tenacious in addressing the requirements
  • Ability to travel to various locations throughout the service area
  • Learns quickly when facing new problems, a relentless and versatile learner. Flexible and adaptable in a rapidly changing environment
  • Ability to work in a team setting with colleagues at different locations
  • Strong organizational skills with the ability to maintain high productivity while assuring accuracy
  • Current licensed NP, LPN, RN, Social Worker other clinical license with 3-5years of clinical experience in critical care or med-surgical experience preferred, or Coder with 3-5 years’ experience in medical field working with HEDIS/QARR metrics or non-clinical experience professional with 3-5 years’ experience working with HEDIS/QARR metrics
  • Strong attention to detail and high level of accountability
  • Work independently with excellent interpersonal skills
  • Ability to use Excel, Word and other software
  • 5-10 years’ experience in a managed care environment and project management experience
  • Advanced clinical assessment skills required
  • Ability to proficiently read and interpret medical records required
  • Knowledge of NCQA/URAC standards preferred
  • Knowledge of HEDIS/QARR/Star, Medicaid incentives specifications
72

Clinical Quality Performance Specialist Resume Examples & Samples

  • Current and unrestricted RN in PA
  • Required 3 – 5 years quality improvement experience within a managed care organization (preferably Medicare)
  • 2 to 4 years of experience in project facilitation/management
  • Demonstrated ability to review data, write reports, and provide both qualitative and quantitative analysis
  • Experience with Health Plan NCQA Accreditation and Quality of Care investigating
  • Required proficiency with Microsoft Office applications including Word, PowerPoint, Excel
73

Nibr Clinical Quality Head Resume Examples & Samples

  • Drive evaluation of existing clinical processes across NIBR for the identification of risks and potential gaps to Novartis and regulatory requirements
  • Work effectively in a matrix environment with stakeholders to prioritize, develop, and implement plans to address these gaps and ensure sustained compliance
  • Lead clinical quality project initiatives/improvement efforts within NIBR. Provide leadership oversight and proactive communication of such efforts
  • Serve as subject matter expert in Good Clinical Practice (GCP) and act as a contact for internal and/or external stakeholders
  • Drive continuous improvement for the Clinical Quality Management System with business partners
  • Interact with internal and external functions to keep abreast with industry issues and trends, interpret Clinical Quality & Compliance intelligence, provide an understanding of how these quality requirements may impact the NIBR organization and recommending appropriate and timely action
  • Facilitate the development and monitoring of the NIBR clinical quality plan activities in alignment with the NIBR business strategy and HA requirements
  • Communicate Clinical Quality results and collaborate with clinical operations areas to mitigate risks, resolve issues and identify resulting process improvements
  • Ensure regulatory commitments of inspections conducted for NIBR clinical trials & processes are met and areas needing quality improvements proactively addressed; this includes but not limited to ensuring that CAPAs, Audits, and remediation activities are effectively aligned with the goals of the business and regulatory expectations
  • Ensure adequate and timely escalation of incidents/issues with business partners and other QA functions
  • Foster a quality culture and jointly maintain the Quality Management processes with early development business owners
  • As a member of the NIBR Quality Leadership team, represent NIBR Quality at key Leadership meetings and forums to provide visibility and input on clinical quality
  • Manage the relevant budget and headcount including building a high performing clinical quality team, talent management and implementation of succession plans
74

Manager of Clinical Quality Resume Examples & Samples

  • Coordinates coverage of local staffing needs, arranging coverage for sick calls and vacation planning and monitors timecard accuracy
  • Provides direct day to day oversight for all assigned staff
  • Delegates tasks to appropriate staff within the QI department
  • Responsible to oversee the completion of the QI quarterly program evaluations, monitoring improvement and compliance
  • Performs direct QI functions for local IPA, as assigned
  • In conjunction with the local Medical Director, Executive Director, and QI Director, implements quality improvement strategies
  • Day to day responsibility for the QI Programs (P4P, 5 STAR, etc.)
  • Communicates changes in policy and procedure to assigned staff
  • Reports performance to targets and works with QI Director to develop intervention strategies
  • Provides lead communication link from denial and appeal unit to the UM department
  • Current and unrestricted RN or LVN license in California
  • 1+ years of experience in lead / supervisory position
  • 1+ years of experience in direct clinical role
  • Knowledge of HMO and MCO operations
  • Experience in the development and implementation of improvement strategies (both clinical and service)
  • Proficient in Microsoft Office products: Word, Excel
  • Knowledge of general PMG / IPA operations
  • Previous experience developing departmental infrastructure
  • Knowledge of continuous quality and utilization/medical management techniques and operations
  • Previous external accreditation experience (NCQA, JCAHO)
  • Experience in Denials, Appeals, and Grievance resolution
75

Clinical Quality Consultant Resume Examples & Samples

  • Advanced MS Office Skills – specifically Excel – must have exceptional analytical and data
  • Ability to accommodate extensive travel (up to 75%) within the service delivery area
  • Representation expertise
76

Clinical Quality Auditor Resume Examples & Samples

  • Bachelor's degree in Medical Technology or equivalent
  • Minimum of 1 year of clinical research experience in regulatory phase trials (e.g. CRA) with high level of competency or
  • Equivalent combination of education and prior directly related experience
  • Registration with the Health Professions Council (HPCSA) as a Clinical Pathology Medical Technologist or the American Society of Clinical Pathology (ASCP), at a generalist level
  • Valid annual licensure with the HPCSA (South Africa)
  • One to two years of bench level experience in a CAP/SANAS accredited / CLIA certified laboratory setting
  • Successful completion of PPD Foundations Training
  • Familiar with ICH-Good Clinical Practices and appropriate regional clinical research regulations (e.g., FDA and other regulatory agency guidelines)
  • Internal candidates must have a thorough working knowledge of PPD Clinical Standard Operating Procedures and Working Practice Documents
  • Excellent oral and written communication skills (including appropriate use of medical and scientific terminology)
  • Able to work independently or in a team environment
  • Good problem solving abilities
  • Basic computer skills in Microsoft Word, Excel and Powerpoint and ability to learn and become proficient with appropriate software
  • Valid driver's license and ability to qualify for and maintain a corporate credit card with sufficient credit line for extensive business travel
  • Superb knowledge of Laboratory Quality systems
77

Unit Based Clinical Quality Leader Resume Examples & Samples

  • Registered Nurse, Masters degree or a BSN and actively enrolled in a graduate program that leads to certification as a CNS within the defined timeframe
  • Clinical background working with patients on the CICU
  • Experience and understanding of community resources and pediatric tertiary care centers
  • Obtaining certification as a Clinical Nurse Specialist within 4 years of start is a condition of employment
  • Current Washington State nursing license
  • At time of hire: Current Basic Life Support (BLS) for Healthcare Providers is required for all positions. Pediatric Emergency Assessment, Recognition and Stabilization (PEARS), and Pediatric Advanced Life Support (PALS) will be accepted in lieu of BLS for Healthcare Providers
  • As a condition of employment: Current BLS for Health Care Providers is to be maintained at all times by all nurses. Note: current PALS and/or PEARS will be accepted in lieu of BLS, and must be maintained as current at all times. Employees are responsible for any costs (including time away from work) associated with obtaining PALS or PEARS certification if it is not a requirement of the position. (ACLS will not be accepted as a substitute to the requirements listed above.)
  • PALS or PEARS Certification may be required for specific departments. PALS is required for the CICU
  • National certification in specialty
78

VP, Clinical Quality Resume Examples & Samples

  • This position currently has the following direct reports
  • Senior Director, Quality Management
  • Senior Director Medicare Star Strategy
  • Director Quality Analytics
  • Senior Project Manager
  • Senior Business Manager
  • Communications Manager
  • Executive Assistant
  • 7-10 years managed care experience, including management/people leadership experience and experience in Quality Management
  • People leadership skills
  • Ability to effectively execute on cross-functional innovative projects in a complex operating environment
  • Excellent verbal and written communication skills, including ability to speak comfortably and extemporaneously to diverse audiences
  • Ability to explain program, clinical, operational, and quantitative information in a business-like, clear, coherent, and comprehensible way to lay people
  • Strong quantitative and analytic skills working with claims, operational, and clinical data and reports
  • Excellent interpersonal communication skills, including active listening, self-management and awareness, emotional intelligence, and ability to flex interpersonal style situationally
  • Good skills with negotiation and creative solutioning
  • Working knowledge/skills with Microsoft Office including Outlook, Word, Excel, and PowerPoint
79

Clinical Quality Production Supervisor Resume Examples & Samples

  • Technical leadership and further development of the Clinical Quality Production Group
  • Coordination and implementation of the in-process controls, the visual final drug testing and the blindness tests for clinical test samples
  • Ensure SOP-compliant release of production orders after completion of cleaning and material acceptance
  • Responsibility for GMP-compliant pattern management
  • Support for the implementation / coordination of cleaning validations in the area of ​​CSS Production
  • Coordination / execution of tasks within the framework of routine monitoring
  • Participation in the investigation of deviations in the production (lead investigator) as well as central contact persons of the supervisors in the production for quality issues
80

Clinical Quality Program Admin Resume Examples & Samples

  • Performs assessments to identify gaps in the enterprise's quality and technology assessment processes and initiates actions to correct these gaps
  • Assures compliance with HEDIS QI work plans
  • Assures QI activities are relevant to the targeted population
  • Acts as the business owner overseeing day to day operations for contracted vendors delivering program and services designed to improve HEDIS/STARS rates
81

Senior Analyst, Clinical & Quality Solutions Resume Examples & Samples

  • Supports client engagement from pre - sales / sales through transition to implementation
  • Develop service offerings and add - on components to increase value of the solution
  • Advanced MS Office Skills - specifically Excel - must have exceptional analytical and data expertise
82

Director System Clinical Quality Resume Examples & Samples

  • Demonstrated ability to align and motivate key process stakeholders, including nurses, physicians, finance and other clinical/administrative staff up to and including Board of Director involvement
  • Active RN license in the state the incumbent resides in
  • Demonstrated ability in PI methodology
  • Demonstrated proficiency with information systems technology
  • Demonstrated workflow process analysis and design
  • Demonstrated facilitation/training skills; demonstrated superior goal accomplishment skills
  • Teach and develop presentation materials for all levels of the organization are key to this role
83

Clinical Quality Spec / Patient Adv Resume Examples & Samples

  • Facilitate resolution of complaints/grievances/requests from Patients & Visitors and ensures regulatory compliance with DPH, DMH, TJC
  • Respond to suggestions and complements submitted by patients and provide feedback to the respective department or staff member
  • Document patient/visitor concerns to include patient demographic data, synopsis of incident, actions taken to resolve, and outcome
  • Input complaints into database, compose letters or e-mails to patients, visitors, or physicians, leadership
  • Analyze complaint/grievance data and collaborate with Director of Quality and Safety to report results on a monthly basis
  • Co-leads the Rights and Responsibility (RI) Chapter of The Joint Commission
  • Prepares timely reports, data, and projects to external and internal regulatory (DPH, DMH, TJC) entities, individuals, departments and assists with interpretation of results
  • Participates in the development, implementation, and on-going education of Clinical Quality initiatives and administrative functions as directed by the Director of Quality and Patient Safety
  • Facilitates and participates in committees and meetings that are focused on Quality, Safety, Performance Improvement, and Patient Relations
  • Serves as a professional role model and mentor to staff by responding positively to change while supporting colleagues through the change process
  • Actively participates in the following committees: The Joint Commission Preparedness Committee, Patient Safety Triage Team, Patient Care Assessment Committee (as guest), Patient Family Advisory Council, and other committees as appropriate
  • Active participant in the Patient Experience Committee
  • Ensures the dignity of patient/customer is maintained at all times
  • Analytical, problem solving, and negotiation skills
  • Superior teamwork skills, both as a leader and a team member
  • Is cooperative in interactions, treating internal and external customers with courtesy, respect and compassion
  • Maintains a professional appearance and demeanor
  • Strives to prevent/resolve customer concerns to the customer's satisfaction
  • Patient when responding to questions and answers questions appropriately
  • Responds to requests in a timely manner, handles interruptions in a skillful way
  • Responds and provides service recovery, must be able to address difficult, awkward situations with tact and diplomacy
  • Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change
  • Attends and participates in Human Rights Officer (HRO) Training
  • Attends and participates in staff meetings, orientations, and in-services and/or reviews documentation as required, actively participates in mentoring
  • Demonstrates strong computer skills with knowledge of control charts and Microsoft applications including Outlook, Word, Excel, Power Point
  • Exception oral and written communication skills; presentation skills; attention to detail
  • Must be an informed regulatory healthcare representative for the patient and organization; must be able to communicate patient and visitor rights and responsibilities to patients, family members, and staff
  • Baccalaureate degree in a nursing, health care, social services, sociology, psychology, customer service, hospitality, or business-related field
  • Human Rights Officer (HRO) Training provided by the Massachusetts Department of Mental Health within 6 months of hire
  • Develops and implements with staff strategies to improve employee engagement
84

Clinical Quality Leader Resume Examples & Samples

  • Bachelors degree in Nursing or an Allied Health profession
  • Eight or more years of recent experience in the acute or medical practice care setting and/or quality management/improvement organizations as relevant to targeted assignments
  • Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) required within one year
  • Quality management and improvement experience
  • Advanced competence with Excel and data analysis
  • Highly effective and experienced at facilitation of teams including complex multi-disciplinary projects
  • Knowledgeable and skilled at managing disparate perspectives and conflict
  • Excellent writing and presentation skills
  • Medical record review/abstraction experience
  • Working knowledge of performance improvement methodologies (i.e. DMAIC), analytic tools and methods; familiarity with basic statistics as related to healthcare quality
  • Experience with implementation of quality/patient safety improvement
  • Relevant computer skills (Excel, PowerPoint, Word, electronic medical records, clinical databases)
  • Excellent leadership, facilitation, and communication (oral, written) skills
  • Exceptionally strong interdisciplinary collaboration skills are needed
  • Evidence of advanced commitment to profession
  • Knowledge of guidelines, healthcare standards, and regulations
  • Experience with clinical outcomes, safety, and patient satisfaction data
  • Evidence of publishable work (research, quality reports, clinical summaries)
85

Clinical Quality Audit Specialist Resume Examples & Samples

  • Conducts file audits as assigned for Care Management clinical adherence which includes utilization management, case management and disease management
  • Participates in the development and ongoing review of audit tool clinical elements that accurately capture adherence with required standards
  • Participates in meetings with Care Management and others to discuss audit findings, areas of opportunity and recommendations for improvement
  • Appropriately escalates areas of concern identified during clinical file audits
  • Required A High School or GED with directly related equivalent experience
  • Preferred An Associate's Degree in Nursing, Clinical Social Work/Counseling
  • Required 3 years of experience in clinical compliance auditing, i.e. CMS, AHCA, NCQA, EQRO or managed care environment
  • Preferred Other Managed Care experience in UM, BH, CM, or DM
  • Preferred Other Familiarity with Medicare and Medicaid programs
  • Intermediate Ability to effectively present information and respond to questions from peers and management
  • Intermediate Ability to work within tight time frames and meet strict deadlines
  • Advanced Ability to work as part of a team
  • Advanced Demonstrated interpersonal/verbal communication skills
  • Intermediate Other Ability to read, analyze and interpret state and federal laws, rules and regulations
  • Advanced Other Ability to assess, analyze, make recommendations and report findings verbally and in a formal written summary
  • Advanced Other Demonstrated technical expertise in performing quality reviews along with analysis of results
  • Required A license in one of the following is required: Other
  • Required Licensed Registered Nurse (RN)
  • Preferred Beginner Microsoft Access
  • Preferred Advanced EMMA
  • Required Advanced InterQual
  • Preferred Intermediate Health care Management Systems (Generic)
86

Clinical Quality Value Analysis Program Manager Resume Examples & Samples

  • Responsible for the Covenant Health Clinical Quality Value Analysis (CQVA) initiative of system-wide medical/surgical supplies and minor equipment standardization. Serves as member and facilitates team activities in conjunction with CQVA chairperson
  • Research products and clinical topics to support decision making of CQVA teams. Uses the Internet, published resources, and networking to maintain expertise in healthcare trends and accomplish necessary research
  • Works with facility leaders to identify and track appropriate supply chain benchmarks against, which organizational performance is monitored. Facilitates implementation of subsequently designed strategies to enhance strategic initiatives and facility operational processes
  • Provides education to CQVA members, managers, physicians and administrators related to costs, best practices, decision-making methodology and processes required to achieve measurable results
  • Sets goals, plans and prioritizes projects, and develops appropriate communication plans. Oversees implementation of project communication and conversion plans
  • Monitor utilization and work to resolve both preference and clinical application contracts standardization compliance issues
  • Act as a resource to Senior Leadership on clinical standardization/utilization issues
  • Maintain professional growth and development through continued education, seminars and specific technical training, to keep abreast of the latest trends in healthcare technology
  • Participates in the System Materials Council to collaborate on developing strategic initiatives and improve Integrated Delivery Network (IDN) operational processes
  • Maintains professional growth and development through seminars, workshops and professional affiliations to keep informed of latest trends in CQVA
  • Attend meetings as required and participates on committees as directed
  • Collaborate with other support and materials staff to add value to the organization through strategic initiatives and operational improvements
  • Collaborate with other support staff to add value to the organization through efforts in clinical standardization, and educational efforts for team members
  • Analyzes data to assist in the development of improvement plans
  • Promotes use of CQVA processes by physicians and facility leaders
  • Provides consultation for medical technology assessment, and supply formulary consistency
  • Coordinates with Supply Chain team during negotiation of contracts and commitment levels with vendor representatives
87

Clinical Quality Review Consultant Resume Examples & Samples

  • Act as a subject matter expert for Humana At Home programs
  • Work collaboratively across teams on various ongoing projects
  • Assist internal and external stakeholders with continuous improvement efforts
  • Facilitate, participate, and communicate with cross-functional teams and work groups to provide subject matter expertise for program delivery to measure performance in meeting Model of Care MOC requirements for care management delivery
  • Develop and/or update process flow documents and definitions
  • Support Learning and Development in development of training materials
  • Serve as a subject matter expert on committees
  • Conduct prospective reviews
  • Support associates and their leaders through guided discussion and feedback
  • Bachelor’s Degree or a minimum of 3+ years’ equivalent experience in quality, compliance, NCQA accreditation, HEDIS, Medicare/ Medicaid experience
  • Must be able to travel as required by the business (up to 10% anticipated)
  • Must have a separate room with a locked door that can be used as a home office to ensure you have absolute and continuous privacy while you work
  • Healthcare audit experience
  • Clinical background with care management or case management background strongly preferred
88

HS Clinical Quality Spec, Senior Resume Examples & Samples

  • Participates in the development and ongoing review of audit tool clinical elements that accurately capture adherence with required standards. Develops process flows with focus on regulatory requirements, documentation of departmental processes, report generation, and process improvement
  • Reviews Care Management program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of audit elements, departmental processes, staff training, and contractual/regulatory standards
  • Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards
  • Reviews policies and procedures, provides updates and collaborates with policy and procedure team to ensure compliance with state and federal regulations. Researches legal/regulatory documentation and performs analysis, including the review and summarization of regulatory requirements, updates, and/or changes
  • Participates as needed with preparation for State and Regulatory audits by collecting and /or reviewing evidence
  • Meets established productivity and accuracy standards for file reviews
  • Follows departmental audit guidelines and processes
  • Other duties and special projects as assigned
  • Required 4+ years of experience in clinical environment (inpatient or outpatient)
  • Required 1+ year of experience in Managed care (UM, BH, CM, DM)
  • Required Other Familiarity with Medicare and Medicaid programs
  • Preferred Other Previous State or Federal care compliance experience
  • Advanced Demonstrated time management and priority setting skills
  • Intermediate Other Ability to read and interpret state and federal laws and regulations in relation to organization clinical documentation
  • Intermediate Other Ability to assess clinical documentation in relation to audit standards and make recommendations for improvement based on findings
  • Required Other A license in on of the following is required
  • Licensed Registered Nurse (RN)
  • Licensed Practical Nurse (LPN)
  • Licensed Mental Health Counselor (LMHC)
  • Licensed Clinical Marriage & Family Therapist (LCMFT)
  • Required Intermediate Microsoft Excel Strong knowledge of Microsoft Office (including Outlook, Word, Excel, Powerpoint, and Access)
  • Required Beginner Microsoft PowerPoint Knowledge of flow charting tool to create and maintain process flows
  • Preferred Beginner SharePoint
  • Preferred Beginner Microsoft Visio