Clinical Quality Resume Samples

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A Gleason

Aidan

Gleason

52344 Maggio Gateway

New York

+1 (555) 969 7505

52344 Maggio Gateway

New York

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

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

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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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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)

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

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

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

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