Senior Clinical Quality Management Analyst (Remote)

Company :

Highmark Wholecare

Job Description : 

JOB SUMMARY

This job works with appropriate departments in the areas of compliance, process improvement and member/provider satisfaction for all product lines. Reviews, researches and responds to customer complaints relating to quality of medical care and service. Recommends and/or implements process improvements related to the potential of quality medical care and service. Serves as a resource regarding accreditation standards including NCQA standards and continuous quality improvement principles. May coordinate accreditation activities on behalf of the organization. Performs special studies per audits, conducting office site visits and medical records reviews, ensuring resolution of member/provider complaints in timely manner. Coordinating credentialing and re-credentialing activities to include QM information, and support preparations for regulatory audits.

ESSENTIAL RESPONSIBILITIES 

• Develop, manage process improvement initiatives from member/providers to include detailed data analysis, process analysis, report generation and documentation.   
• Conduct, collect and analyze data from office site and/or medical record reviews to continually improve the care and service to members and coordination with the credentialing and quality improvement programs to achieve and maintain accreditation.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan.
• Conduct annual audits, identify gaps, communicate results and re-audit.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor’s Degree in a Healthcare-related field or current state RN license

Substitutions

• 6 years of progressive Medical Coding experience

Preferred

• None

EXPERIENCE

Required

• 5-10 years of relevant, progressive experience in the area of specialization

Preferred

• 1 - 3 years of demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
• 1 - 3 years of prior project management experience preferred
• 1 - 2 years Total Quality Management (TQM) concepts, techniques, process and outcome measurements
• 1 - 2 years of statistics in order to analyze various reports and validate study methodologies

LICENSES AND CERTIFICATIONS

Required

• None

Preferred

• None

Preferred

• None

SKILLS

• Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles.   Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring and problem resolution
• Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data

Language (other than English)

None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Rarely

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Does Not Apply

Physical work site required 

No

Lifting: up to 10 pounds

Occasionally

Lifting up to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Never

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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