Clinical Quality Management - EPSDT Coordinator

JOB SUMMARY  

This job is responsible for working with appropriate departments in the areas of compliance and process improvement for all product lines. Reviews, researches and responds to clinical data relating to quality of medical care. Recommends and/or implements interventions related to the improvement of medical care and costs. Serves as a corporate resource regarding related accreditation standards including NCQA, CMS, URAC, etc., clinical performance and continuous improvement principles. Coordinates related accreditation activities on behalf of the organization. May perform: special studies or audits, practice guideline development and monitoring, network provider performance measurement and monitoring, activities to educate or influence the behavior of members and/or providers. Acts as subject matter expert for the corporation. 

Candidates should reside in the state of DE or within reasonable distance to travel within the state.
 

ESSENTIAL RESPONSIBILITIES  

• Develop and manage large projects targeting members and/or network providers to improve clinical care provided to health plan members, including data analysis; visualizing and resolving complex problems; and developing and implementing interventions across the Organization networks.
• Organize and provide consultative support to relevant corporate stakeholders to address key barriers to appropriate member clinical care.
• Coordinate and manage the position-specific quality improvement programs to maintain regulatory compliance and quality accreditation for the corporation.
• Fulfill the role of subject matter expert for the corporation regarding activities related to applicable quality standards.
• Other duties as assigned or requested.

  EXPERIENCE  

 
Required  

• 5 years of Relevant progressive experience in the area of specialization
• 1 year of Experience with continuous quality improvement processes including project planning and managing multiple priorities
• 1 year of Experience interpreting regulations and assessing plan impact, implementing processes to enhance compliance, and auditing results.

Preferred  

• Work experience using TQM and/or continuous process analysis and improvement fundamentals.
• Work experience demonstrating use of analytical and problem-solving skills.
• Work experience with moderately complex projects but known methods of resolution; extremely complex projects and previously untested methods of resolution.
• Work experience in quality/credentialing activities or related business areas

SKILLS  

• Communicate effectively with appropriate levels of organization (including senior management) and external stakeholders to ensure project completion
• Work collaboratively with all levels of staff, external stakeholders, and representatives from applicable regulatory/accrediting bodies
• Work independently, identify issues that place the plan at risk, and effectively communicate these concerns to management in a timely manner. This job requires the ability to recognize and balance business and operational constraints without jeopardizing compliance

EDUCATION  

 
Required  

• Bachelor's degree in Nursing with current state licensure or bachelor's degree in other clinical field such as Physicial Therapy, Social Work, or Psychology

Substitutions

• 4 years of relevant experience in lieu of bachelor's degree

Preferred  

 
Language (Other than English):  

None 

Travel Requirement:  

0% - 25% 

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS  

Position Type  

Office- or Remote-based 

Teaches / trains others 

Occasionally 

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

Rarely 

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

Never 

Physical work site required 

No 

Lifting: up to 10 pounds 

Constantly 

Lifting: 10 to 25 pounds 

Occasionally 

Lifting: 25 to 50 pounds 

Rarely 

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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.  
 
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.   
 
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.