Clinical Quality Manager in New York, NY at Pride Health

Date Posted: 11/17/2019

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    New York, NY
  • Experience:
    Not Specified
  • Date Posted:
    11/17/2019

Job Description

Clinical Quality Manager

Provides consultative services and manages quality improvement activities and initiatives.  Analyze performance and recommends improvement initiatives and/or corrective actions.  Utilizes quality improvement framework, Plan, Do, Study, Act, to facilitate rapid cycle improvement strategies.  Serves as a resource to quality improvement committees and work groups.  Integrates compliance and regulatory requirements into quality improvement processes. 

EXPERIENCE: Minimum of four years clinical experience in a health care setting, including at least two years with a focus on quality improvement and measurement, required.  Knowledge of health care delivery systems, patient care, care coordination, and clinical processes required.  Ability to perform statistical/quantitative analysis required.  Experience processing Medicare and Medicaid appeals required. Excellent oral, written and interpersonal communication skills required. Knowledge of basic Performance Improvement tools and methodologies preferred.

Work with clinical management to identify, develop and implement quality improvement standards and criteria that meet program goals.  Evaluate effectiveness of standards and recommends changes, as needed.

Communicate and establish protocols and standards of care for a cultural and demographic diverse patient/member population; provide intervention guidelines based on these population health needs.

Coach and facilitate performance improvement activities designed to help teams and programs meet and exceed quality scorecard indicators.  Instructs management and staff in the meaning and use of data for the purpose of assessing and improving quality.

Participate in the development of standards and criteria for monitoring compliance with Federal and State regulatory requirements and performance standards of care.  Develop performance measures and data collection instruments. 

Facilitate quality assurance and utilization review activities with interdisciplinary teams on ways to improve and positively affect the care that is provided to patients/members. Review and analyze changes in the health status and outcomes of patients/members utilizing outcomes data.  Consult and collaborate with clinical staff to identify trends and opportunities for improvement in health status and outcomes.

Collaborate with stakeholders in the development of action plans based on quality reviews and root cause analysis findings.  Make recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies.

Follow-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.

Conduct audits of patient/member case records. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology.

Keep informed of the latest internal and external issues and trends in utilization and quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership.  Revise/develop processes, policies and procedures to address these trends.

Perform onsite medical record reviews for HEDIS or other related compliance or quality improvement initiatives.

Specialized Skill and Technical Competency:

Demonstrates working knowledge of all federal, state, local and regulatory agency requirements as related to the department and position.

Demonstrates basic ability to use Microsoft Office, Word, PowerPoint, Excel and Access.

LICENSURE: Current license and registration to practice as a Registered Professional Nurse in New York State required.  Valid driver's license or NYS Non-Driver photo ID card.

EDUCATION: Bachelor’s or Master’s Degree in Nursing required.