Clinical Quality Manager Resume Samples

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K Marvin

Kali

Marvin

90264 Concepcion Drive

Los Angeles

+1 (555) 413 0135

90264 Concepcion Drive

Los Angeles

Phone

p +1 (555) 413 0135

Experience Experience

San Francisco, CA

Clinical Quality Manager

San Francisco, CA

Krajcik Inc

San Francisco, CA

Clinical Quality Manager

Assist with the implementation of the National HEDIS improvement plan, including the HEDIS data collection and clinical improvement projects
Assist with the development, organization and implementation of companywide quality improvement efforts
Assists with investigative reports for federal, state, and third party payers with regard to IRF-PPS, IP/OP utilization, quality, and performance improvement
Assists with analyzing and trends data related to complaint management performance, patient satisfaction, etc
Manage the development and delivery of reviewer training for assigned projects
Assist in developing targeted educational reminders for clinical/preventive initiatives
Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation

Phoenix, AZ

Clinical Guidance Quality Manager

Phoenix, AZ

King Inc

Phoenix, AZ

Clinical Guidance Quality Manager

Compliance to accreditation, state, and federal regulations
Collection of annual HEDIS data. Review of final reports and participation in barrier analysis
Manages the development and analysis of statistical data and specifications to determine benchmark standards
Partners with departments for data analysis and development of scorecards for QM reporting
Coordination of medical record audit and results reporting / trending
Develops and implements methods and procedures for monitoring work activities in order to keep management informed of current overall quality status including identified improvement opportunities
Educates staff regarding quality improvement process

present

San Francisco, CA

Manager Auditor Clinical Quality Management

San Francisco, CA

Boyer Inc

present

San Francisco, CA

Manager Auditor Clinical Quality Management

present

Serves as a subject-matter expert in the Deviation process; supports the business in documenting and closing deviations
Working with CQM colleagues, assists in the follow-up and escalation process for Corrective Actions Preventive Actions (CAPA) identified via the audit process
Manage processes and activities within the GQM group as assigned; may act as an SME for a system or a process
Drives or participates in the optimization and/or execution of assigned GQM operational responsibilities
May be responsible for oversight of Document Management
Prepares and delivers internal and external presentations, as assigned
Serve as line-manager for contingent workers responsible for GQM activities

Education Education

Bachelor’s Degree in Life Sciences

Boston University

Bachelor’s Degree in Life Sciences

Skills Skills

Excellent teamwork and collaboration skills
At least 3 years of experience with HEDIS or Healthcare Quality Assurance Broad clinical knowledge of disease, medical procedures, medical claims coding and Provider office processes
Excellent oral and written communication skills
Strong leadership and management skills
Ability to lead multidisciplinary groups to meet defined goals
Personal computer experience, proficient with Microsoft Office suite
Ability to access and navigate multiple data systems and software applications to store and retrieve data
Strong analytic skills with practical knowledge of how to identify key performance quality metrics to set targets for maintaining a state of compliance while identifying areas for improvement
Strong analytical and critical thinking skills
Extensive experience auditing clinical CRO's, clinical sites and investigator sites

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Clinical Guidance Quality Manager Resume Examples & Samples

Compliance to accreditation, state, and federal regulations
Collection of annual HEDIS data. Review of final reports and participation in barrier analysis
Accountable for organizational performance in areas of clinical quality, core measures and regulatory readiness
Manages the development and analysis of statistical data and specifications to determine benchmark standards
Establish proposed quality and reliability expectancy
Partners with departments for data analysis and development of scorecards for QM reporting
Assists with formulation of quality objectives and coordination of objectives to maximize quality outcomes, meet established standards and minimize costs when applicable through efficiency design / re-design
Coordination of medical record audit and results reporting / trending
Develops and implements methods and procedures for monitoring work activities in order to keep management informed of current overall quality status including identified improvement opportunities
Educates staff regarding quality improvement process
The role supports information management structures through knowledge of existing software to assist in the collection and analysis of data for performance patterns, trends and opportunities for improvement
Interact with leaders within the organization to promote programs and strategic initiatives
Knowledge of NCQA recognition programs
Interact with leaders/associates of multiple health plans/payors (Humana, CarePlus, etc)
RN-BSN, Bachelor's degree or Quality management experience focused in the Healthcare/Managed care/Medical Center environment
Must possess working knowledge of HEDIS and NCQA standards
Experience in data collection and analysis, developing and executing performance improvement action plans and attaining organizational goals
Bilingual Skills – English/Spanish - able to speak, read, and write fluently
Experience in leading teams
MS Outlook, Word, and Excel
Must have the ability to travel 75%, including to Tampa and Orlando
MBA or other Advanced Degree
Demonstrated experience with process documentation and re-engineering
Strong Math aptitude

Clinical Audit Quality Manager & Internal HBA Resume Examples & Samples

Consult with other business areas to create cost benefit analyses and prioritize current projects
Collect, analyze and communicate competitive intelligence to influence network development strategies
Prepare and present recommendations to both internal and external audiences
Resolve general issues and defects
Bachelor’s in Nursing (BSN)
Certified Medical coder with one of the following credentials: CCS, RHIT, RHIA
Leadership experience minimum of 1 year
Clinical Quality experience
Minimum of 2 years medical record auditing experience with inpatient facility claims
Progressive experience in the health service industry, healthcare finance or healthcare related consulting
Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information
Excellent writing, editing, interpersonal, planning, teamwork, and communications skills
Ability to work independently and manage work load
Certified Medical Audit Specialist
Strong knowledge of Microsoft Access
Proven proficiency across a wide range of services, which include evaluation and management, anesthesia, surgical services, radiology, pathology and medicine
Strong written and verbal communication skills; strong analytical, organizational and time management skills

Clinical Nurse Analyst / Quality Manager Resume Examples & Samples

Identify and review clinical medical records of military casualties for data abstraction, coding and special studies
Perform data searches of various Department of Defense (DOD) databases for medical encounter data from selected or participating fleet, naval force, individual vessels or commands
Abstract and analyze clinical information from military casualty reports to determine patient diagnoses and complications for population of database
Participate in development of Quality Assurance activities related to data abstraction and coding
Clinical expert/consultant for department on nursing and current trends in patient care
Ability to participate in customer requests for information and prepare a variety of progress and status reports
Keeps abreast of clinical trends and new technologies in healthcare

Clinical Quality Manager Resume Examples & Samples

Serve as the HEDIS subject matter expert
Partner to provide direct and active assistance to Inovalon clients (internal and external) in the management of operational execution and resolution of client questions, concerns and service issues
Hold responsibility for the quality and efficiency of the assigned quality review team
Assist with the design, execution, and management of ongoing quality assessment procedures for all review personnel
Ensure quality review team is maintaining high standards of quality and reliability
Enforce quality requirements and standards
Assist with the development, organization and implementation of companywide quality improvement efforts
Maintain the control and ongoing monitoring of quality and reliability as well as quality reporting mechanisms and management tools
Ensure compliance with contractual, local, state and national quality standards
Provide direct feedback, quality /process counseling and coaching, retraining and when necessary reassignment or termination decisions for review personnel regarding quality issues
Manage the development and delivery of reviewer training for assigned projects
Assist with the oversight and management of Inovalon’s training processes (both initial and ongoing training) for all review personnel
Maintain oversight of the quality and effectiveness of all review staff during training and through project execution
Maintain open lines of communication with Director(s) of Quality, Operational Support Team, Learning and Development and Client Service Managers regarding on-going overread and quality activity as it relates to client and operations management
Make recommendations for process and technical changes, and document changes to custom review training materials; and
Assist the Director(s) of Quality in performing IRR and Over-read accuracy testing for all review and quality personnel according to contract requirements and provide results data to Client Service Managers for communication to clients
RN/LPN with 5 years work experience, preferably with medical record review and chart abstraction
Indepth, working knowledge of HEDIS specifications
Ability to effectively interact with clients (internal and external) in verbal and written communication
Advanced knowledge of Microsoft Office applications including Excel and Outlook
Project and personnel management experience required
Exceptional problem solving, analytical, interpersonal and communication skills to resolve issues within Quality
Professionally skilled in verbal and written communication; and
Meticulous organization skills, with the ability to multi-task, and the ability to make sound decisions in a timely and independent manner

Clinical Quality Manager Resume Examples & Samples

Participate in determination of annual HEDIS strategy as well as other clinical improvements
Participate with Regional Quality Team to identify and implement region and or state-specific projects to improve HEDIS scores, CMS Star Ratings and other metrics
Participate in regional quality programs and committees as needed
Minimum of 2 years Healthcare/Health Plan experience
Strong data management and/or project management skills
Solid knowledge of managed care requirements related to clinical quality
Excellent team development skills
Strong proficiency with Microsoft Office applications, including: Word, Excel and PowerPoint
Experience working with HEDIS software vendors (management, building relationships, issue resolution etc.)
Experienced in medical record review
Proficiency with Microsoft Access

Clinical Quality Manager Resume Examples & Samples

Bachelor’s Degree in Nursing
Registered Nurse with current in-state RN license
Minimum 2 years quality management experience within past 5 years
Expertise in data management, statistical analysis, and reporting
Excellent organizational skills and attention to detail
Computer skills that include basic Word, PowerPoint, and Excel
Certification in a recognized professional UM/QM organization. (i.e., CPHQ)
Current experience with regulatory agency guidelines and regulations such as TJC, URAC, CMS, and NCQA
Proficiency in project management

Hedis Clinical Quality Manager Resume Examples & Samples

Assist with the implementation of the National HEDIS improvement plan, including the HEDIS data collection and clinical improvement projects
Collaborate with the HEDIS Project Managers in the collection of RFI, ROADMAP and HOQ information for HEDIS
Identify opportunities and actively participate in process improvements related to enhancing health plan quality
Assist in developing targeted educational reminders for clinical/preventive initiatives
HEDIS experience and/or knowledge
Demonstrated ability to assist with focusing activities toward a strategic direction and achieve targets
Clinical and/or Health Education experience (RN or LPN desired)
Basic statistical knowledge and application of continuous quality improvement concepts, such as Six Sigma or PDSA

Hedis Clinical Quality Manager Resume Examples & Samples

Minimum of 1 year HEDIS experience and/or knowledge
SAS and/or SQL experience
Basic statistical knowledge and application of continuous

Clinical Quality Manager Resume Examples & Samples

Experience working with Providers and Provider Office staff
Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation
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
Manages and is accountable for professional employees and / or supervisors
Impact of work is most often at the local level
RN Licensure in the state of LA
3+ yrs. supervising / managing staff
2+ yrs. experience with NCQA
2+ yrs. experience with HEDIS project management
Experience with Microsoft Excel, Powerpoint and Visio
Must live in the state Louisiana

Clinical Quality Manager Resume Examples & Samples

Healthcare/Health Plan experience
Demonstrated ability to manage multiple projects simultaneously
Ability to collect, analyze, and present data
3+ years of healthcare experience
Minimum of 2 years HEDIS experience and/or knowledge

Clinical Quality Manager Resume Examples & Samples

3 Years. 5 Years preferred
Degree in Nursing or related clinical field with current clinical licensure in State of California. Supervisory level experience in clinical quality assurance and utilization review
Working knowledge of JCAHO, Medicare, Medi-Cal, HMO and managed care requirements

Clinical Informatics Quality Manager Resume Examples & Samples

Develop method for efficient quality measure production that leverages reusable components of rules
Oversee creation, quality testing, and validation of quality measures
Develop and maintain documentation of measure definitions – both clinical and technical
Oversee ongoing review of data integrity, data coding, and measure processing issues and their impact on product quality. Design and/or delegate corrective interventions
Establish governance process for measure management, including issues around multiple versions of measures and retired measures
Contribute to strategic planning for new measure development
Be a trusted advisor to clients for choosing measures and anticipating issues with deployment of measures
Work with internal staff and clients to write specifications for measures
Work with production teams and client implementation teams to ensure data feeds are set-up properly
All other job related duties as it relates to the job function or as delegated by the management team
This position reports to the Director, Clinical Informatics
Direct Reports (titles): BA and QA Resources (potentially up to 3 resources)
Indirect Reports (titles): N/A
Ability to gather/analyze/document business requirements leading to the development of a business solution
Knowledge and/or experience in using requirements analysis techniques such as
Bachelor’s Degree in computer science, IT, operational research or equivalent work experience
5+ years experience as business analyst with relevant experience in rules engines
Clinical training a strong plus
Experience working with clinicians a strong plus
Data governance, especially as it pertains to maintaining a large repository of rules and relevant output for analytics
Familiarity with clinical coding is a plus (i.e. ICD-9, ICD-10, CPT, HCPCS, Revenue Codes, LOINC, NDC)

Clinical Quality Manager Resume Examples & Samples

*This position can be located at any UnitedHealth Group location in the U.S.***
Minimum of 1 year of experience working with HEDIS vendors, demonstrated ability specific to management, building relationships, issue resolution etc
Adaptable to a highly changing environment; ability to quickly shift focus as priorities change
Build trust and form effective relationships with stakeholders by providing timely operational updates, partnering on issue resolution/mitigation strategies
Communicate effectively and persuasively, excellent interpersonal and communication skills, both written and verbal
Experience coordinating work streams across multiple business partners, emphasis on collaboration and issue resolution

Hedis Clinical Quality Manager Resume Examples & Samples

Undergraduate degree or demonstrated equivalent experience
Minimum of 4 years Healthcare/Health Plan experience
Minimum of 2 years HEDIS experience and/or medical record review
Experience working with Providers/Provider Groups
Knowledge of CMS STARs
Application of continuous quality improvement concepts, such as Six Sigma or PDSA

Clinical Quality Manager Resume Examples & Samples

Collects and analyzes data for medical staff and hospital wide quality functions, through review of a variety of records and reports, interviewing, observation, supportive literature, and other methods, as appropriate
Collects and analyzes data to support Peer Review, physician profiling, quality assurance, and performance improvement activities
Assists with analyzing and trends safety and patient occurrence data
Assists with analyzing and trends data related to complaint management performance, patient satisfaction, etc
Completes medical record reviews, including data collection, content review, and reporting. Provides education on documentation requirements as defined by Medicare and TJC
Assists with performance improvement initiatives/activities. Leads/facilitates teams as appropriate
Investigates quality and risk issues with regard to patient occurrence reports, complaint and/or quality related cases
Assists with investigative reports for federal, state, and third party payers with regard to IRF-PPS, IP/OP utilization, quality, and performance improvement
Assists with organizational compliance with TJC, CARF, Federal, and State regulations related to quality
Assists with the development and enhancement of data collection procedures and data analysis processes
Supervises the Infection Control Nurse in the implementation of the Hospital Infection Control program
Performs other duties as requested
Baccalaureate Degree in related field required. Master’s Degree preferred
Current state licensure as a Registered Nurse
Previous experience in Quality Improvement, with Statistical Process Control experience and computer skills preferred
Demonstrates familiarity with accrediting standards, including TJC and CARF preferred
Current membership/certification in the national and State Association of Quality Assurance Professional preferred

Clinical Quality Manager Resume Examples & Samples

Drive the implementation of the quality requirements within the PLS clinical team. Monitor and track implementation of the annual Quality Plan deliverables together with the supported CT including the quality risk assessments and inspection readiness components for the designated trials
Provide Quality input and oversight for the execution of clinical trials or respective services under the responsibility of PLS
Lead the quality requirement assessment for new services in close collaboration with the business teams
Lead the clinical part of the local Quality Review Board to ensure appropriate management review of all quality and compliance related topics including the review of key quality indicators (KQI); identify appropriate continuous improvement initiatives for quality and compliance related areas
Support strategic CT Quality and Business initiatives, including the design and implementation of respective quality and compliance activities and affected changes, the support of remediation programs and the development and implementation of strategic process improvement
Facilitate effective communications within the CT and by interacting with other QA functions and the customer QA in line with established quality agreements
Ensure that applicable PLS clinical processes are implemented in line with the service scope. Help to establish in-built controls in relevant process steps to ensure adherence to regulatory compliance
Monitor effectiveness of implementation of applicable clinical processes through KQIs in collaboration with business process owners to demonstrate that processes are in control and ensure required compliance levels
Implement and lead the process to regularly review and assess KQIs at the respective CTs. Ensure that potential gaps and risks are addressed and opportunities for continuous improvement identified
Ensure and provide effective Quality oversight and management for the following areas: a. Adequate and timely escalation of incidents/issues within CTs and QA. b. Timely and effective initiation of investigations c. Definition of adequate CAPAs are defined, their implementation and effective closure tracked d. Qualification and management of vendors for outsourced activities
Degree in Life Sciences, Pharmacy or Medicines
Advanced degree a plus
Fluency in English (oral and written)
At least 4 - 6 years of involvement in regulated activities, clinical development and QA positions; broad understanding of global expectations of Health Authorities in the area of Clinical Development; profound understanding of the science of product development
A minimum of 3 years experience in managing projects
Ability to effectively interact with and present to senior management at all levels, as well as to external audiences and inspectors
Strong skills in GCP, quality and/or clinical development
Strong interpersonal, communication, negotiation, and problem solving skills
Strong project management skills desirable
Considerable organization awareness (e.g. interrelationship of departments, business priorities), including significant experience working cross-functionally and in global teams Knowledge and understanding of cultural differences and diversity issues

Clinical Quality Manager Resume Examples & Samples

Lead assigned providers and large provider collaborations to improve HEDIS, CAHPS and STARS scores and improve member outcomes through innovative, data driven initiatives
Monitor quality performance of assigned providers and develop action plans in collaboration with key stakeholders for continuous quality/process improvements
Participate in quality improvement initiatives and manage associated projects, including data collection, quality improvement aids and evaluation of program effectiveness for members
Conducts medical record reviews, including electronic medical records, to support regulatory requirements for the purposes of plan audits, HEDIS and Star Ratings
Request missing documentation, from providers via telephone, fax, written correspondence, on-site visits or review of electronic data necessary to make informed clinical decisions
Document clinical data in appropriate systems
Conduct reviews of member complaints related to Quality of Care and Quality of Service issues and provide resolution within mandated timelines
Support CMS reporting requirements for quality topics such as Serious Reportable Adverse Events (SRAE) and Sentinel Events
Act as a clinical liaison for Credentialing operations
Participate in the Quality Management Committee, Quality Improvement Committee and supports completion of annual quality improvement work plan and reports as needed
Participates in the NCQA accreditation processes as needed
Degree in Health Services Field or equivalent combination of education and experience
At least 3 years of experience with HEDIS or Healthcare Quality Assurance Broad clinical knowledge of disease, medical procedures, medical claims coding and Provider office processes
Ability to lead multidisciplinary groups to meet defined goals
Ability to handle multiple assignments; prioritize, excel in fast–paced, deadline–orientated, detail-driven environment, flexing as business needs and demands change
Personal computer experience, proficient with Microsoft Office suite
Ability to access and navigate multiple data systems and software applications to store and retrieve data

PRN RN Manager of Clinical Practice & Quality Assurance Resume Examples & Samples

Minimum of one year in a clinical management role
OASIS certified or will be required to obtain OASIS certification within 1 year of hire as a MCP
Must possess the ability to lead and manage clinicians and office staff for successful patient outcomes and clinical and branch performance

Project Manager, Clinical Quality Assurance Resume Examples & Samples

Lead a group or team of cross functional/cross divisional employees in the achievement of organizational and project specific goals. Guide, coach, direct, and develop direct/indirect reports, and if applicable, drive those practices throughout their organization
Lead group Kaizen and other continuous improvement events/projects to drive cost, compliance and/or capacity improvement
Direct and control the activities of one or more projects/programs and/or operations
Communicate status, risks, and resolutions to Quality and Clinical Leadership on key initiatives
Monitor and ensure compliance with regulatory requirements, standards, company policies and procedures (e.g. federal/country and regulatory requirements)
Interprets and executes policies that affect work processes and personnel within the assigned organizational unit
Contributes to the development of operational policies and procedures that affect personnel within the assigned organizational unit
Keeps abreast of and interprets current worldwide regulatory requirements; advises management on the possible ramifications of regulatory changes
Partners with Clinical project teams in divisions and regions (e.g. Latin America, AMEA), influences clinical teams toward a state of inspection readiness at all times
Communicates observations to clinical program managers, directors, and management. Participates in problem-solving with project teams
May support annual audit planning, review and trending of audit results, and development and implementation of improvement initiatives
Supports the preparation, coordination, and management of regulatory agency sponsor inspections of BSC offices
Assists in preparation of investigator sites for FDA or other regulatory agency inspections and assists in preparation of written responses to findings
Support to the Clinical organization in meeting BSC Quality system requirements
Owns key Corporate CAPA’s, leads cross divisional teams in addressing compliance issues using CAPA tools/processes
Bachelor’s degree in Life Sciences, Engineering, or related field
Minimum 8 years experience in medical device or pharmaceutical industry in an area regulated by GCP regulations and guidelines; 5 years clinical QA experience; direct clinical quality (GCP) auditing experience preferred but not required
Project Management or other business process improvement experience required
Travel up to 25% can be expected
Medical device experience desired

Clinical Quality Manager Resume Examples & Samples

Master's Degree preferred with minimal 10 years' experience in Biotech or Pharma and 5+ years' experience in Quality Systems related to GCP
Strong analytic skills with practical knowledge of how to identify key performance quality metrics to set targets for maintaining a state of compliance while identifying areas for improvement
Extensive experience auditing clinical CRO's, clinical sites and investigator sites
Understanding of domestic and international regulatory requirements
Outstanding communication skills (interpersonal, verbal and written)
Proven track record of industry success
Excellent teamwork and collaboration skills

Manager, Clinical Quality Assurance Resume Examples & Samples

Coordinate and conduct Sponsor, site and vendor audits, as well as Regulatory Inspections
Track and resolve SOP Deviations on a company wide basis and manage Corrective Action/Preventative Action (CAPA) Investigations on company-wide basis
Assist in development and management of audit programs for clinical studies and functional area oversight
Provide internal consulting to project teams as needed; and
Collaborate with outside clients/sponsors as needed

Manager Auditor Clinical Quality Management Resume Examples & Samples

Manage processes and activities within the GQM group as assigned; may act as an SME for a system or a process
Serve as line-manager for contingent workers responsible for GQM activities
Responsible for the preparation, conduct and reporting for routine and directed clinical investigator site, Vendor, Partner, Pre-Qualification, internal and external partner and both domestic and international as assigned
Drives or participates in the optimization and/or execution of assigned GQM operational responsibilities
May be responsible for oversight of Document Management
Serves as a subject-matter expert in the Deviation process; supports the business in documenting and closing deviations
Independently provides GCP guidance and shares expertise in the interpretation of clinical development regulations and Good Clinical Practice (GCP) guidelines
Inspection Readiness activities and regulatory authority inspection and/or external audit support
Properly escalates issues and risks to the Otsuka business to GQM Leadership
Performs activities that support overall departmental and business goals and objectives
Exhibits significant competencies related to all GQM systems and procedures
Serve as Mentor for new staff when requested
Good Pharmacovigilance Practices (GVP) experience preferred
Open to additional training as deemed applicable (i.e. GVP, Document Management, CSV etc.)
Strong computer skills of MS Office applications and SharePoint (Word, Excel, PowerPoint Outlook…)
Knowledge of applying organizational policy or procedures to a variety of situations
Self-driven, comfortable supporting others, innovative