Salary Range

$80k to $120,000 annually.

Location

Hybrid – Atlanta, GA

Primary Responsibilities

• Actively researches and develops interventions that can be used to improve performance and clinical quality and support HEDIS, clinical measures and the accreditation process.
• Identifies, leads and facilitates performance improvement projects and initiatives, measurement and analysis for Medicare programs, processes, and outcomes.
• Develops and writes business cases and quality improvement plans, charters, and reports.
• Builds a dynamic culture of member safety by developing and leading clinical aspects of the Quality of Care (QOC) process.
• Engages with healthcare teams in the development and adoption of QI frameworks, performance improvement around nationally endorsed quality measures, strategy development that drives a culture of continuous quality improvement, by leveraging those relationships.
• Evaluates data needs and collaborates with other analytics teams to identify opportunities which support departmental and divisional goals.
• Assists others within the Quality Department in study design, planning for data collection, root cause analysis and implementing solutions.
• Performance and Improvement Initiatives: Conducts audits that supports regulatory and accreditation requirements, including audits of external vendors and delegates, internal processes, and clinical measures, such as HEDIS and Stars
• Serves as a subject matter expert consulting with external representatives including provider office staff and delegates.
• Develops major quality improvement activities and programs that encompass research, study design, population, and outcome analysis.
• Leads multidisciplinary efforts to develop population health programs and clinical guidelines designed to improve quality of care.
• Optimizes the use of existing information resources and develops additional resources.
• Reviews documentation for compliance; audits processes; interviews appropriate management, and staff; assists with gap analysis and the development and monitoring of corrective action plans.
• Serves as a resource to staff and delegates seeking to better understand the accreditation/regulatory agency standards and aids in the development of internal action plans to assist others in development of processes and protocols within their department.
• Annual Quality Review and Development of Work Plan: Participates in the annual update of quality improvement (QI) program description and QI work plan.
• Collaborates with Health Services partners in the development and revision of the annual Model of Care
• Assists with the evaluation of the effectiveness of the QI program and its related improvement projects, as well as identification of performance improvement opportunities.
• Report Development: Develops and writes performance improvement plans in accordance with regulatory and accreditation requirements.
• Reviews and edits documents which will be utilized with both internal and external audiences.
• Coordinates the Quality-of-Care process by reviewing weekly concurrent review reports and ensuring other QOC referrals are appropriately screened and processed.
• Facilitates the thorough investigation of potential QOC concerns and the Peer Review Committee alongside the medical director.
• Continues to develop and monitors “Track and Trend” database for effective reporting to appropriate committees.
• Serves as a SME on issues related to clinical quality and program development.
• Regularly appraises and updates relevant quality measures and benchmarks to align with Sonder Health Plans’ overall strategy.
• Manages and collaborates with committees related to clinical quality, performance improvement, risk and accreditation requirements such as the Peer Review, Fraud Waste and Abuse, Credentialing, Risk and Delegated Oversight Committees
• Manages relevant workplans, agenda management, meeting minutes and follow-up items.
• Co-Chairs the Plan’s Quality Improvement Committee (QIC) meetings quarterly, creates agenda, minutes, communicates with all department heads for their individual presentations and manages stipends / expenses for committee community physician consultants.
• Manages relationship and collaboration with the HEDIS vendor, HEDIS auditor and survey vendors.
• Responsible for Plans CCIP (Chronic Care Improvement Program) document, updates, and submission to CMS annually

Required Qualifications

• Registered Nurse with licensure in Georgia
• 5 years of previous clinical experience in primary care, specialty, or acute care setting
• Bachelor’s Degree from a college or university in clinical discipline or any combination of education and experience providing the types and levels of knowledge, skills, and abilities required by the job.
• 4 years’ experience in a healthcare-related organization assessing (auditing) for regulatory and accreditation compliance, clinical quality improvement, and conducting and documenting performance improvement initiatives to address accrediting and regulatory bodies.
• Clinical and service quality program management
• Demonstrated experience in design and implementation of large-scale quality improvement projects.
• Advanced knowledge of organizational assessments for compliance against accreditation and regulatory requirements
• Advanced knowledge of medical terminology; health plan HEDIS and CAHPS; Utilization Management and Case Management standards
• Knowledge of quality improvement principles and project management, including formal training or certification and proven experience leading relevant business process improvement projects and/or quality improvement projects or teams

Preferred Qualifications

• Master’s degree in healthcare administration, Business or Statistics
• Intermediate level knowledge of health plan data HEDIS, CAHPS, and HOS
• Intermediate level knowledge of Microsoft Office Access applications
• Preferred certifications include: CPHQ or equivalent healthcare QI, Lean/Six Sigma, PMP or equivalent project management certification.