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Clinical Quality Improvement Specialist & Reviewer (Registered Nurse)

Job Ref: 64844
Category: Quality Assurance
Department: QUALITY MANAGEMENT
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $100,000.00
Salary Range: $100,000.00 - $100,000.00

About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

The function of the Clinical Quality Improvement Specialist & Reviewer is to design, implement and evaluate complex quality and process improvement projects required to
support public health, HEDIS, QARR, Stars and other regulatory needs for complex chronic care conditions. These functions are carried out in a cost effective and
measurable design model.


The Clinical Quality Improvement Specialist & Reviewer in accordance with NYS DOHand CMS regulatory guidelines and MetroPlus Health Plan policies and procedures also conducts quality of care (QOC) and critical/adverse incident reviews of clinical interactions and clinical documentation from provider treatment records under the
direction of the Plan Medical Director.

Job Description

Design, implement and evaluate complex quality and process improvement projects required to support public health, HEDIS, QARR, Stars and other regulatory needs to
drive specific clinical quality improvement outcomes. Provide clinical reviews of Quality of Care (QOC) and Critical/Adverse incidents in accordance with NYS DOH
and CMS regulatory guidelines.
- Research, develop and identify internal and external barriers/root causes thataffect the health status of plan members and ensure the implementation of strategies to overcome these barriers.
- Develop methods and/or tools to collect and track barriers for targeted members and providers. Methods may include but not be limited to surveys, focus groups, visits to provider offices/hospitals, community events or healthcare organizations.
- Create plans/interventions based on barrier, data, and/or competitor analyses, defined project scope and goals, measurable metrics for program evaluations,
and projected timelines.
- Develop member and provider communications that are clear, direct and actionable.
- Apply analytics to identify and target various populations to drive quality improvement and measurable outcomes.
- Evaluates interventions for project/intervention continuation and or modification to provide for continuous process improvement.
- Develops tools and supports for the physicians, provider groups, etc. relative to measures/desired outcomes for specific diseases to drive quality improvement.
- Document findings for each initiative and presents results to applicable departments and management.
- Analyze member and provider data for assigned healthcare quality measures and/or population to identify trend and target population/area for quality improvement projects.

Data sources and tools may include but not be limited to the following:
o Statistically significant changes in rates/stratifications
o Member and provider information from government and vendor’s reports and datasets and internal databases.
- Perform medical record review, including review of electronic medical records to investigate clinical quality of care (QOC) complaints. Review provider records against clinical and procedural established standards.
- Ensure timely and accurate QOC case resolution within NYS DOH and CMS regulatory requirements dependent online of business.
- Ensure each QOC review is supported by nationally recognized and accepted sources/clinical practice guidelines. Provide citations and references in support of findings and for use in member communications.
- Implement and monitor provider corrective action plans as needed. Ensure provider responses are received timely and actions are implemented.
- Collect, analyze and prepare quarterly quality of care report(s) for the Quality Management Committee and Quality Assurance Performance Improvement Committee of the Board. Provide follow-up as requested.
- Participate in the recredentialing process by providing information regarding provider QOC complaints, medical record review as needed to track and trend provider careand follow up on provider corrective action plans. Attend Credentialing/Recredentialing Subcommittee meetings monthly.
- Track and trend clinical quality of care/adverse incidents from a population perspective and identify opportunities for improvement.
- Prepare reports to fulfill CMS reporting requirements for quality reporting including but not limited to Reportable Adverse Events.
- All other duties as assigned at the discretion of Quality Management Leadership.
 

Minimum Qualifications

Bachelor’s degree in a clinical field required. Advanced degree preferred.


Current licensed RN required


Must have a minimum of 5 years’ experience in the health care field.


Quality Improvement experience in a managed care environment preferred.

Superior oral, written and communications skills. Ability to understand and communicate analytic and clinical data to varied audiences.


Solid analytical and logical skills paired with strong attention to details.


Must be a versatile, quick learner, who is open to change and enjoys the challenge of unfamiliar tasks.


Superior project management and documentation skills.


Must be action oriented, producing results on projects that require risk taking with minimal planning, while keeping self-control during high activity periods.


Ability to function well independently and in team setting.


Must be able to make effective and timely decisions by organizing information in a useful manner and orchestrating multiple activities at once to accomplish the goal.


Must work effectively with others, fostering open dialogue, accountability and common mindsets within the team.


Must have integrity, fostering an honest and trusting relationship with coworkers and management, never compromising the Plan, other employees or self for personal gain.


Must seek to continuously improve processes for the benefit of the customer by taking personal responsibility for the resolution of customer services.


Must be proficient in Microsoft Word, PowerPoint, Excel and Access.


Experience with and proficient in data analysis. Working knowledge of relational database and statistical analyses is a plus.


Must be familiar with and have a working knowledge with QI process improvement methodology strategies including but not limited to PDSA and DMAIC.

Must be familiar with the HEDIS, QARR requirements.


Knowledge and understanding of regulatory requirements, specifically CMS and NYS DOH as they are applied to Clinical Quality of Care reviews.


Knowledge and understanding of NYS HIPAA and Privacy Rules.


Must possess analytical skills in order to collect, organize and present data in a clear and concise manner.


Ability to assess all work and prioritize as necessary to meet reporting timeframes and deadlines.


Six Sigma Yellow or Green Belt preferred.