Clinical Quality Management Consultant

Job ID: J134693
Company: Gateway Health Plan
Location: Home, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Nov 12, 2018

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Description

  • JOB SUMMARY

    This job is responsible for working with appropriate departments in the areas of compliance and process improvement for all product lines.  Reviews, researches and responds to clinical data relating to quality of medical care.  Recommends and/or implements interventions related to the improvement of medical care and costs.  Serves as a corporate resource regarding related accreditation standards including NCQA, CMS, URAC, etc., clinical performance and continuous improvement principles.  Coordinates related accreditation activities on behalf of the organization.  May perform: special studies or audits, practice guideline development and monitoring, network provider performance measurement and monitoring, activities to educate or influence the behavior of members and/or providers. Acts as subject matter expert for the corporation. While the role will be work from home, the first 6 months will require onboarding in the Gateway offices.

    ESSENTIAL RESPONSIBILITIES

    • Develop and manage large projects targeting members and/or network providers to improve clinical care provided to health plan members, including data analysis; visualizing and resolving complex problems; and developing and implementing interventions across the Organization networks.
    • Organize and provide consultative support to relevant corporate stakeholders to address key barriers to appropriate member clinical care.
    • Coordinate and manage the position-specific quality improvement programs to maintain regulatory compliance and quality accreditation for the corporation.
    • Fulfill the role of subject matter expert for the corporation regarding activities related to applicable quality standards.
    • Other duties as assigned or requested.

    QUALIFICATIONS

    Minimum

    • Bachelors Degree in Nursing with current state licensure or bachelors degree in other clinical field such as physical therapy or social work, or psychology
    • 5-10 years of relevant progressive experience in the area of specialization
    • Experience with  continuous quality improvement processes including project planning and managing multiple priorities
    • Experience interpreting regulations and assessing plan impact, implementing processes to enhance compliance, and auditing results

    Preferred

    • Master’s Degree
    • Work experience using TQM and/or continuous process analysis and improvement fundamentals
    • Work experience demonstrating use of analytical and problem solving skills
    • Work experience with moderately complex projects but known methods of resolution; extremely complex projects but known methods of resolution; and extremely complex and previously untested methods of resolution
    • Work experience in quality/credentialing activities or related business areas

    Skills

    • Communicate effectively with appropriate levels of organization (including senior management) and external stakeholders to ensure project completion
    • Work collaboratively with all levels of staff, external stakeholders, and representatives from applicable regulatory/accrediting bodies
    • Work independently, identify issues that place the plan at risk, and effectively communicate these concerns to management in a timely manner.  This job requires the ability to recognize and balance business and operational constraints without jeopardizing compliance

     

    WORK ENVIRONMENT

    Is Travel Required?

    Yes  - (The job will involve site visits throughout Pennsylvania with short notice. Work from home will begin after a 3-6 month onboarding period.)

    Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

    Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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