Clinical Quality Specialist Resume Samples
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Clinical Quality Specialist Resume Samples
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MH
M Hintz
Maxwell
Hintz
22676 Hugh Plain
Los Angeles
CA
+1 (555) 543 9014
22676 Hugh Plain
Los Angeles
CA
Phone
p
+1 (555) 543 9014
Experience
Experience
Dallas, TX
Clinical Quality Specialist
Dallas, TX
Paucek-Romaguera
Dallas, TX
Clinical Quality Specialist
- Assists in revising methodology for tracking review of physicians as requested by Committee or Department chairman and maintains all statistics related to QA
- Prepare statistical reports outlining department error rates/trends at least quarterly for review at the Quality Enterprise Committee meeting
- Monitoring activities will be performed through observation of Facets UM, Clinical Care Advance, focused file reviews and policy and procedures
- Provide feedback to all associated departments with quality monitoring variances and document corrective action and follow up
- Responsible for providing consistent and effective updates to the Vice President of Clinical Services for all assigned responsibilities
- Assists to PRO reviews within requested timeframes and assists in preparing correspondence in response to QA inquiries
- Responsible for Oversight of Clinical and Regulatory Operations to include in-direct supervision of facility department heads
Philadelphia, PA
Clinical Quality Specialist / Nurse
Philadelphia, PA
Kirlin LLC
Philadelphia, PA
Clinical Quality Specialist / Nurse
- Troubleshoot quality challenges on site at health care facilities. Use independent clinically-based judgement to review, evaluate and address customer quality challenges
- Provide clinical training and support to SPT staff
- Participate in risk analysis activities for new and existing products, provide clinical insight and review
- Provide sales and marketing support in terms of quality
- Develop strong relationships with customers and Medline sales reps
- Formal presentations of SPT quality initiatives to current and potential Medline customers and sales reps
- Analyze customer specific quality data and map proactive engagement strategies to address quality trends
present
Chicago, IL
Clinical Quality Specialist Senior
Chicago, IL
Lubowitz-Harber
present
Chicago, IL
Clinical Quality Specialist Senior
present
- Patient Safety Program - Assists with the development and implementation of patient safety initiatives that will reduce medical errors and increase beneficiary safety. Through the PQI and other CQM process, identifies opportunities, mechanisms and interventions directed to either or both beneficiaries and providers throughout the continuum of care. Tracks and reports the effectiveness of specific interventions
- Assists the Manager with action plan development for HEDIS like metrics
- Committee Meetings – Prepares for and participates in meetings. Prepares documentation and presents CQM activities, proposals, outcomes, reports and initiatives
- Participates in Quality Studies – Performs quality review studies based on CQM program indicators to determine compliance with evidence based clinical guidelines or nationally recognized quality benchmarks
- Oversees grievances – Processes grievances to ensure eligible, aggrieved parties obtain an explanation for and/or a correction of any perceived failure of a network provider or any associate or subcontractor
- Works with the clients to create plans to improve results when results are less than expected
- Assists in developing department policies and procedures
Education
Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
Kent State University
Bachelor’s Degree in Nursing
Skills
Skills
- Strong attention to detail
- Advanced Other Ability to assess, analyze, make recommendations and report findings verbally and in a formal written summary
- 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
- Excellent oral and written communication skills
- Intermediate Other Ability to read, analyze and interpret state and federal laws, rules and regulations
- Review summary data with the Quality Management and Performance Improvement Director and regional leaders
- Advanced Other Demonstrated technical expertise in performing quality reviews along with analysis of results
- Microsoft office proficiency
15 Clinical Quality Specialist resume templates
Read our complete resume writing guides
1
Rn Clinical Quality Specialist Quality & Outcomes Management Hour Days Resume Examples & Samples
- Five years or more in an acute care setting preferred. Must have least 2 years of critical care experience, preferably recent experience. Requires critical thinking skills and organization in prioritizing a workload of multiple tasks. Experience in quality improvement/peer review preferred. Management experience preferred. Works independently with minimal instruction. Demonstrates excellent verbal and written skills
- Current Registered Nurse License, CPHQ preferred
- Competency validated to perform abstraction of information into Quantros for Core Measures, SCIP and any other applicable initiative
- A Fire and Safety card must be presented upon hire or must be obtained at our facility within the first 30 days of hire and maintained by renewing before expiration date
2
Clinical Quality Specialist, Informatics Resume Examples & Samples
- 2 – 5 years of practical experience in supporting the data preparation requirements of an interdisciplinary team in a large-scale data analytic context
- Must be knowledgeable about existing programs available for data validation and data cleansing
- Experience with high-level analytical tools and data formats
- Experience in statistics, algorithms, graph-based software
- At least 3 years experience in a healthcare environment
- Demonstrated ability to adapt easily to change and lead others in a team environment
- A proven track record in the use of a clinical quality database
- Biostatistics skills-specific experience with statistical methods for data collection and analysis
- Certification preferred: in six sigma or informatics or will obtain within 1 year of hire
3
Clinical Quality Specialist Quality & Outcomes Management Resume Examples & Samples
- Experience in quality improvement/peer review preferred
- Demonstrates attributes of the Keck Service Culture; possesses excellent verbal and written skills
- Demonstrates knowledge of acceptable professional standards and practices
- Ability to review, summarize, analyze and display clinical quality and outcomes data
- Proven ability to prioritize and manage to completion multiple detailed and complex projects simultaneously
- California Registered Nursing License
- CPHQ or required to obtain within 2-years of employment
4
Clinical Quality Specialist Resume Examples & Samples
- 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
- Participates in meetings with Care Management and others to discuss audit findings, areas of opportunity and recommendations for improvement
- Preferred Other Managed Care experience in UM, BH, CM, or DM
- 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 Demonstrated interpersonal/verbal communication skills
- Intermediate Other Ability to read, analyze and interpret state and federal laws, rules and regulations
- Required Licensed Registered Nurse (RN)
- Preferred Beginner Microsoft Access
- Preferred Advanced EMMA
- Required Advanced InterQual
5
RN Clinical Quality Specialist Resume Examples & Samples
- Conducts review of UM, CM and DM cases to assure accuracy and compliance with UM plan, CMS, NCQA, and Department of Insurance guidelines
- Utilizes audit tools to perform documentation audits on job functions within Care Management
- Bachelor of Science in Nursing, Healthcare Administration or a related field required. (Eight additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree)
- Registered Nurse with current license in Texas, or other participating States
- Five or more years of progressively responsible healthcare experience to include experience in a managed care setting, and / or hospital settings, and / or physician practice setting
- Three or more years of experience in managed care with at least two years of Utilization Management experience
- Knowledge and experience with CMS, URAC and / or NCQA
- Must be willing to occasionally travel in and / or out-of-town as deemed necessary
- Health Plan or MSO quality, audit or compliance experience
- Strong knowledge of Medicare and TDI regulatory standards
- Previous auditing, training or leadership experience
6
Clinical Quality Specialist Senior Resume Examples & Samples
- Demonstrates regular, reliable and predictable attendance
- Evaluates performance results
- Works with the clients to create plans to improve results when results are less than expected
- Handles Potential Quality Issues (PQIs) – Processes and reviews all identified PQIs that may represent quality or patient safety issues
- Participates in Quality Studies – Performs quality review studies based on CQM program indicators to determine compliance with evidence based clinical guidelines or nationally recognized quality benchmarks
- Oversees grievances – Processes grievances to ensure eligible, aggrieved parties obtain an explanation for and/or a correction of any perceived failure of a network provider or any associate or subcontractor
- Patient Safety Program - Assists with the development and implementation of patient safety initiatives that will reduce medical errors and increase beneficiary safety. Through the PQI and other CQM process, identifies opportunities, mechanisms and interventions directed to either or both beneficiaries and providers throughout the continuum of care. Tracks and reports the effectiveness of specific interventions
- Quality Management Activity Reports - Produces monthly, quarterly and annual reports utilizing standardized
- Committee Meetings – Prepares for and participates in meetings. Prepares documentation and presents CQM activities, proposals, outcomes, reports and initiatives
- Trains staff regarding the processing of PQIs, grievance, medical record reviews and studies
- Assigns and oversees workload of the staff
- Assists the Manager with action plan development for HEDIS like metrics
- Conducts monthly internal audits and reporting; provides feedback to staff regarding audit results
- Assists in developing department policies and procedures
- Demonstrated ability for assessment, evaluation and interpretation of medical and/or behavioral health information
- Demonstrated leadership, assessment and organizational skills
- Excellent interpersonal skills, and the ability to work effectively and to make independent decisions
- Knowledge of national standards, sate and federal laws relating to review for quality of care
- Knowledge of a variety of clinical specialties areas of medical or behavioral health treatment, practices and procedures
- Skilled in the operation of the computer including proficiency in Microsoft Office Word, Excel and Access
- Knowledge of ICD-9-CM, CPT, HCPCS and DRG desired
7
HS Clinical Quality Specialist Resume Examples & Samples
- Participates in the development and ongoing review of audit tool clinical elements that accurately capture adherence with required standards
- Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards
- Meets established productivity and accuracy standards for file reviews
- Required A High School or GED with directly related equivalent experience
- Intermediate Demonstrated time management and priority setting skills
- Advanced Ability to work as part of a team
- Required A license in one of the following is required: Other
- Required Licensed Practical Nurse (LPN)
- Required Licensed Clinical Social Worker (LCSW)
- Required Licensed Mental Health Counselor (LMHC)
- Required Intermediate Microsoft Excel
8
Clinical Quality Specialist Per Diem Days Resume Examples & Samples
- Must have a working knowledge of Core Measure abstraction guidelines and have oversight of the core measure abstraction process, conduct analysis and performance improvement initiatives to improve outcomes of core measures, prepare in-services and educate staff and physicians on core measure guidelines while improving outcomes and sustaining improvements
- Coordinates and supports the Medical Staff Peer Review process to include but not limited to medical record reviews, Ongoing Physician Performance Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). In addition, performs professional objective medical record reviews for quality of care referrals using evidence-based outcomes and clinical guidelines to identify process deficits trends and/or practice patterns and reports to the appropriate Medical Staff representative and DCQI
- Manages the process of prospective and retrospective medical record review to ensure appropriate documentation supporting medical necessity for surgical procedures and continued staff for medical care. Will work as a liaison between clinicians and financial intermediaries as well as refer pertinent cases to peer review. Will develop physician documentation expectations and educational programs and process tools for physicians, physician office staff and hospital personnel before scheduling procedures
- Works collaboratively with the DCQI in the reduction of readmission program and serves as a liaison for services related to heart failure, pneumonia, and AMI patient’s to avoid readmissions to the hospital
- Participates on assigned performance improvement initiatives throughout the hospital and services as a resource for the hospital quality improvement program
- Current license as Registered Nurse or License Vocational Nurse in the State of California or other health related field
- Two to three years experience in an acute care facility
- Possess excellent organizational and analytical skills
- Possess ability to plan, organize and integrate complex and inter-departmental programs
- Knowledge of Core Measure abstraction process and guidelines
- Knowledgeable in use of computers and specific software including Microsoft Office Word, Excel, Access
9
Clinical Quality Specialist Resume Examples & Samples
- Assists the Director with the operations of the QRM Department and reports at least monthly as to the status of data reporting and progress in meeting goals and timeframes
- Provides Medical Staff Committees with resource information pertaining to the peer review process and assists with the developing of care and quality indicators including medical staff clinical quality reports
- Educates physicians and staff of QA standards and progress and assists them in meeting the regulations and standards as requested by Joint Commission, OSHA, CMS, and AHCA, etc
- Attends Medical Staff meetings, as requested, that pertain to the Peer Review process and completes OPPE and FPPE reports, which are incorporated into the re-credentialing process
- Assists with outside agencies where QA issues are involved as assigned and takes minutes, creates agendas and organizes meetings with other departments when necessary
- Assists to PRO reviews within requested timeframes and assists in preparing correspondence in response to QA inquiries
- Assists in revising methodology for tracking review of physicians as requested by Committee or Department chairman and maintains all statistics related to QA
10
Clinical Quality Specialist Resume Examples & Samples
- Current state licensure (RN), 3 years clinical experience preferred
- Interpersonal skills in order to interact with hospital personnel and physicians
- Computer skills as well as data trending and analysis
11
Clinical Quality Specialist Resume Examples & Samples
- Participates in and helps assure staff compliance with organizational and/or regulatory quality initiatives, i.e. AAAHC core standards. Conducts and participates in audits of nursing care and processes throughout entire network
- Assists with onboarding and introducing Clinical Quality to new hires. Ensures the appropriate orientation and continuing educational development for staff. Monitors and evaluates current curriculum based on research, best practice or professional standards
- Develops and maintains ongoing quality assurance schedule
- Acts as a resource for managers, supervisors, directors, other clinical quality coordinators to facilitate ongoing learning and self-improvement
- Supervises the monitoring of equipment functionality and needs in clinical care acquiring staff and physician input
- Reviews nurses ' and nursing support staff notes to ensure that they are informative and descriptive of the nursing care being provided and that they reflect the patient's response to the care
- Facilitates nursing and nursing support staff participation in patient centered medical home collaboration with our patients
- Assists in investigation of adverse events, assessing for trends and acting on remediation needs
- Collaborates with operations and non-nursing departments to establish processes and address issues which enhance the provision of patient care and satisfaction
- Develop, maintain, and periodically update written job descriptions for each level of nursing personnel
- Maintain a reference library of written nursing material that will assist the nursing services in meeting the day-to-day needs of the patient
- Perform administrative and other duties as necessary
12
RN Clinical Quality Specialist Resume Examples & Samples
- Five years or more in an acute care setting preferred
- Must have least 2 years of critical care experience, preferably recent experience
- Requires critical thinking skills and organization in prioritizing a workload of multiple tasks. Experience in quality improvement/peer review preferred
- Works independently with minimal instruction. Demonstrates excellent verbal and written skills
13
Clinical Quality Specialist Resume Examples & Samples
- Responsible for providing consistent and effective updates to the Vice President of Clinical Services for all assigned responsibilities
- Responsible for Oversight of Clinical and Regulatory Operations to include in-direct supervision of facility department heads
- Responsible for Oversight and Performance Management of the Company’s Risk Monitoring effort with focus on specific regions including but limited to the following areas
- Responsible for collaborating on clinically oriented census development opportunities (i.e. Clinical product development) and expense reduction opportunities (i.e. pharmacy reductions) in conjunction with the district/region operating teams
- Responsible for implementing all Company Clinical and Regulatory Strategic Goals, including new or revised company systems, policies and procedures and programs
- Monitors and encourages achievement of goals and objectives consistent with established company philosophy and standards of practice. Responsible for providing executive clinical leadership to certain defined operations ensuring an effective Quality Improvement Process with favorable clinical trends
- Conducts Focus Compliance audits and Corporate Clinical Services Compliance audits as assigned
- Regularly and consistently reviews clinical performance trends and indicators to identify trends. Provides necessary clinical leadership to address all unfavorable trends and outcomes
14
Health Services, Clinical Quality Specialist Resume Examples & Samples
- Conducts file audits as assigned for Care Management clinical adherence which includes utilization management, case management and disease management
- Appropriately escalates areas of concern identified during clinical file audits
- Participates as needed with preparation for State and Regulatory audits by collecting and /or reviewing evidence
- Follows departmental audit guidelines and processes
- 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 Familiarity with Medicare and Medicaid programs
- 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
- Preferred Intermediate Health care Management Systems (Generic)
15
Principal Clinical Quality Specialist Resume Examples & Samples
- 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, EU MDR, MedDev)
- 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
- Capable of performing work remotely
- Excellent written and oral communication skills and ability to interface professionally and diplomatically throughout all levels of the organization
- Ability to work with international teams
- Ability to manage time efficiently and multi-task
- Ability to prioritize tasks using a risk based approach
- Able to manage complex tasks
16
Senior Clinical Quality Specialist Resume Examples & Samples
- Adopt and implement the Global/ Regional Quality Management Plan within the scope of the assignment; this will include
- Good organizational, interpersonal and communication skills
- Demonstrated ability to work in a matrix environment
- Bachelor's degree in life sciences or equivalent nursing qualification with a minimum of 5 years' experience in Clinical Monitoring including at least 2 years' experience in a role equivalent to a Clinical Project Manager/Clinical Team Lead preferably within Quintiles; or equivalent combination of education, training and experience
17
Clinical Quality Specialist / Nurse Resume Examples & Samples
- Troubleshoot quality challenges on site at health care facilities. Use independent clinically-based judgement to review, evaluate and address customer quality challenges
- Use clinical expertise to evaluate hospital processes that may impact the success of a Medline Sterile Procedural Tray
- Analyze customer specific quality data and map proactive engagement strategies to address quality trends
- Develop strong relationships with customers and Medline sales reps
- Provide sales and marketing support in terms of quality
- Formal presentations of SPT quality initiatives to current and potential Medline customers and sales reps
- Participate in risk analysis activities for new and existing products, provide clinical insight and review
- Provide clinical training and support to SPT staff
- Travel up to 50% of the time for business purposes (within state and out of state)
18
Clinical Quality Specialist Hours Days Resume Examples & Samples
- Excel proficient
- Experienced in data analytics – ie. run chart etc
- Highly preferred but not required - Experience with retrieving reports from Epic is preferred, but not required. Experience with retrieving reports from electronic medical records and working with IS partners to build reports
- Preferred National Database of Quality Indicator (NDNQI) experience, but not required
- Preferred, but not required a master’s degree in informatics or health care informatics. However, without a master degree in informatics, must demonstrate a minimum of 3 years job experience in this area
19
Clinical Quality Specialist Resume Examples & Samples
- Responsible for performing quality monitoring activities of clinical and non-clinical areas for compliance with National Committee for Quality Assurance (NCQA), Special Needs Plan (SNP) (if applicable), URAC standards and state/federal requirements
- Monitoring activities will be performed through observation of Facets UM, Clinical Care Advance, focused file reviews and policy and procedures
- Assist in identifying and evaluating the organizations risk areas related to accreditation, state and federal requirements and provide input to effectively communicate evaluation and recommendations to management
- Responsible for conducting independent random and scheduled monitoring activities for all departments associated with NCQA, URAC, SNP (if applicable), and state quality assurance monitoring requirements
- Analyze the quality assurance results and make recommendations for corrective action when problems are identified
- Provide feedback to all associated departments with quality monitoring variances and document corrective action and follow up
- Provide documentation for discussion at meetings and prepare minutes with follow-up action items
- Prepare statistical reports outlining department error rates/trends at least quarterly for review at the Quality Enterprise Committee meeting
- Ensures corrective action plans are logged and followed
- Functions as a resource for business and clinical personnel in resolving questions related to documentation requirements and quality monitoring activities
- Responsible for ongoing education programs within all departments that have quality monitoring requirements related to accreditation, state and federal requirements
- Perform any other job related instructions, as requested
- Completion of an accredited Registered Nurse (RN) degree program is required
- Minimum of three (3) years of experience in managed care is preferred
- Experience in case management, managed care terms, and practices or utilization review is preferred
- Accreditation experience is preferred
- Microsoft office proficiency
- Demonstrated customer service orientation
- Knowledge of NCQA/HEDIS
- Strong people/interpersonal skills
- Strong organizational, problem solving and decision-making skills
20
Clinical Quality Specialist Resume Examples & Samples
- Bachelor’s degree (technical or non-technical)
- 2 years experience (no experience with a M.S. degree) directly supporting clinical research within a regulated environment, or other relevant quality experience in a regulated environment
- Strong interpersonal skills, ability to work with teams and be a self-initiator
- Fluency in English and Spanish (Portuguese also highly desirable)
