Senior Quality Improvement Specialist

The Senior Quality Improvement Specialist leads and supports organization-wide quality improvement functions targeting quality of clinical care, member experience, operational performance improvement, and contractual and regulatory requirements. These activities cover all Plan’s product lines and may require collaborative work with external stakeholders, including the Plan’s network providers and state and federal agencies. This position provides leadership to multi-disciplinary quality improvement workgroups in the collection, analysis and reporting of data and in the development of intervention strategies in support of quality improvement efforts. The Sr. QI Specialist leads and supports improvement efforts targeting quality and operational measures related to contractual and regulatory requirements and pay-for-performance programs and identifies and communicates areas where the organization is at risk of failing to meet contractual or pay-for-performance goals.

Duties and Responsibilities

Responsibilities include, but are not limited to the following: 

• Maintain an in-depth knowledge of quality improvement requirements for all product lines, including Chronic Care Improvement Program
• Lead the development and implementation of a comprehensive Model of Care oversight program including evaluation of the effectiveness of the Model of Care
• Lead the updates and successful submission of the Model of Care as required by CMS
• Develop written reports inclusive of qualitative and quantitative analysis outlining conclusions and recommendations for improvement in support of the Model of Care
• Lead the preparation and submission of reports on regulatory-required quality improvement projects including the Chronic Care Improvement Program
• Lead and support quality improvement projects for all product lines, inclusive of data collection, quantitative and qualitative analysis and report preparation, with specific responsibilities for the quality improvement workgroups established to obtain the highest pay for performance incentives for all the product lines
• Lead and support identification and implementation of quality improvement activities across the organization and in collaboration with external stakeholders, as necessary, targeting high-priority quality measures
• Maintain an in-depth knowledge of the National Committee for Quality Assurance (NCQA) accreditation requirements for health plan accreditation survey for all product lines including requirements for Model of Care
• Interpret quality-related contractual and regulatory requirements and leads in the development of documentation to support the organization’s compliance with those requirements
• Develop and implement comprehensive plans for assigned responsibilities including delineated tasks, resource requirements, and timelines and milestones, using appropriate tools 

• Apply expertise in utilizing internal and external data sources and benchmarks to meet the analytic challenges posed by quality improvement cycles
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Required:

• Bachelor’s degree in Business or Health-related field or sufficient work experience in a quality improvement position for a minimum of 5 years in lieu of a degree
• Five (5)+ years’ experience working in a managed care organization or a health care-related organization
• Experience working with quality improvement methods and strategies, health care analytics, regulatory requirements and project management
• Demonstrated experience with Medicare/CMS requirements
• Experience working with statistical analysis of complex health care data sets, including health care claims, health surveys and health outcomes data, to support improvement activities
• Strong analytical, attention to detail and critical thinking skills
• Demonstrated expertise in interpreting and operationalizing contractual and regulatory requirements, including the identification and mitigation of associated risks
• Proven ability to develop and implement detailed project plans, including managing multiple projects simultaneously in a deadline driven environment
• Excellent interpersonal skills, including the ability to work across the organization and to interact, influence and negotiate effectively at all levels of management as well as externally
• Confident team builder and leader with strong motivational and problem solving skills
• Effective communication skills, both verbal and written
• Outstanding time management and organizational skills
• Proficient in Microsoft Excel, PowerPoint and Word

Preferred:

• Five (5)+ years’ experience working in a managed care environment with focus on quality improvement, health care analytics and quality improvement requirements
• Experience with Medicare stars program
• Expertise in interpreting and operationalizing contractual and regulatory requirements
• Experience in demonstrating leadership, influence and collaboration in a matrix-managed environment
• Knowledge of medical coding systems used for diagnoses, procedures, pharmaceuticals and clinical laboratory data
• National Association of Healthcare Quality certification as a Certified Professional in Healthcare Quality/Organizational Excellence (CPHQ/OE) or similar QI training

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.