Quality Improvement Specialist

General Summary of Position
Accountable for continuous systematic monitoring of all MedStar Family Choice (MFC) network participating provider processes and outcomes. Responsible for the quality oversight of assigned delegated entities which must meet the established standards set by the State,and NCQA. Actively participates in special quality projects. Actively participates and conducts quality audits; i.e. HEDIS, NCQA, and the External Quality Review Organization (EQRO). Coordinates and conducts medical record reviews and abstracts data. Records information in the Care Management Platform and hybrid record capture tool for HEDIS. Must maintain a minimum of 95% data entry accuracy for auditing purposes. Data entry accuracy is a critical function as errors can result in a non-report for the HEDIS care measure impacting the HEDIS rate and NCQA rating. Contacts members to educate them about wellness initiatives that align with the State of Maryland's Value Based Purchasing initiatives, HEDIS standards and Performance Improvement Projects. Accountable for all contact and following through with member's primary care provider or specialist. Responsible for the completion and notification of MCO members identified with HIV and AIDS to the Maryland Department of Health (MDH). Coordinates the quality and performance improvement of MFC providers through onsite delivery and education of provider reporting on HEDIS measures and Performance Improvement projects. We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
• Accesses data from multiple computer programs (Identifi, Vestica, Centricity, Powerchart, Amalga, MRDI, Member Manager and MedConnect) to determine if patients are compliant with care. Utilizes Microsoft Office to create, sort, and develop lists of records to be reviewed.
• Accurately documents all members' appointments and outreach efforts, successful and unsuccessful in the clinical software system per MFC policy. Responsible for obtaining a copy of the completed services to track compliance and overall utilization score.
• Assists in the preparation of annual summary reports/executive summaries for CAHPS, Provider Satisfaction and EPSDT.
• Assists in the preparation of reports and materials for audits and actively participates in audits, i.e. HEDIS, NCQA, and EQRO.
• Assists the QI Coordinators in planning cross departmental meetings for the purpose of designing and implementing interventions for members, providers, and MFC employees relevant to the states Performance Improvement Projects (PIP). Executes the interventions and gathers relevant materials to prepare the PIP Reports for submission to the state.
• Attends and contributes content to the monthly Quality Improvement staff meetings. Assists the Quality Improvement Manager with maintaining accurate and thorough meeting minutes.
• Attends the Quality Improvement and Utilization Management Committee (QI/UM) meetings and other meetings as directed.
• Completes additional research as necessary to update changing status of member diagnosis (ie progression of disease from HIV to AIDS), and then submits additional capitation information to MDH. Maintains and updates all systems appropriately.
• Coordinates and conducts medical records reviews and abstracts data as needed. May be required to travel to provider offices to obtain medical records.
• Documents accurately, all members appointments and outreach efforts, successful and unsuccessful in the clinical software system per MFC policy. May be responsible for obtaining a copy of the completed services to track compliance and overall utilization score.
• Documents all work related to ensuring MFC receives the appropriate capitation for HIV/AIDS members in the clinical software system and additional member database. Accountable for assuring and maintaining the integrity of information in clinical software system and member database. Maintains HIPPA and confidentiality of all HIV/AIDS clinical information.
• Performs necessary research/requests to obtain the required laboratory confirmation of HIV/AIDS members from the providers office (or facilities and OON laboratories) when MDH requests additional clinical information on members previously identified.
• Performs other duties as assigned.
• Processes the development, preparation, and implementation of Quality Improvement Activities for MFC.
• Provides face to face, telephonic, and written feedback to healthcare providers to apprise them of services that are still needed for patients in order for them to be compliant with HEDIS and Value Based Purchasing measures. Works directly with provider offices to inform them of their Quality and performance on HEDIS measures and educates them on opportunities for improvement. Travel to offices may be required.
• Receives and reviews reports used to identify MFC members with HIV/AIDS. Completes and submits the required, appropriate special capitation enrollee form to MDH. Collaborates with Finance to determine if the special capitation has been received. Responsible for collaborating with Finance and charged with all necessary follow up with MDH to ensure MFC receives timely expected capitation for members with HIV/AIDS.
• Records the information in various databases developed for the specific program or project, maintaining a minimum of 95% data entry accuracy for auditing purposes.
• Responsible for ensuring received laboratory data from LabCorp ( or facilities, providers and OON laboratories) is electronically faxed to the provider office. Reviews the laboratory findings and communicates the results to the appropriate Medical Director, Chronic Care Coordinator or Case Manager. Documents and uploads all work in the clinical software system and member database.
• Responsible for the quality oversight of assigned delegated entities by attending oversight meetings. Reviews delegated entities yearly plans and appraisals to ensure they meet established standards set by the State regulations and NCQA.

Minimum Qualifications
Education

• Associate's degree required or
• equivalent experience required and
• Bachelor's degree preferred

Experience

• Clinical experience in an outpatient setting, medicaid experience preferred

Knowledge, Skills, and Abilities

• Knowledge of HIPAA security standards and internal confidentiality policies.
• Knowledge of medical terminology.
• Ability to enter and retrieve information using a PC.
• Working knowledge of Microsoft Office software applications.

This position has a hiring range of $28.2 - $47.3