QI Project Manager, Sr
Posted on: May 19, 2019
Supports the development and implementation of quality improvement
interventions and audits and assists in resolving deficiencies that
impact plan compliance to regulatory and accreditation standards.
Drives key quality improvement projects requiring the ability to
work effectively in a matrix environment in order to receive needed
data that reflects the overall health of the plan. Department:
Health Services Location: Newark, NJ Reports To: Senior Manager
- Establishes and/or revises existing WellCare policies and
procedures necessary for successful implementation of the Quality
Improvement (QI) Program.
- Pursues methods to ensure receipt of relevant data, as required
for accurate trending of various QI work plan metrics.
- Analyzes key plan metrics, such as top diagnoses, clinical
procedures, and operational performance, to enable the development
of sound and valid recommendations regarding and prioritization of
clinical and service improvement initiatives.
- Works with QI Director to convene various QI committees and
work groups, set agenda to drive desired meeting outcomes (based on
contract and accreditation requirements), and ensure proper
recording of committee activities.
- Acts as knowledge expert for continuous quality improvement
activities, educating staff of other functional areas regarding the
QI process and accreditation requirements.
- Performs various quality department functions and processes,
such as quality of care complaint/adverse event review and
assessment of medical record review results and recommend actions
to address any identified improvement opportunities.
- Manages and monitors clinical quality studies to include
receipt and analysis of trended data, assessment of national
benchmarks as available, development of improvement recommendations
(to include ROI and best practice interventions as appropriate),
presentation to senior leadership, implementation of plan, and
evaluation for desired result.
- Recommends strategies to improve member compliance to QI
program activities, addressing methods to change knowledge,
attitudes and behaviors, such as handbook content, newsletter
articles, member outreach interventions, and member focus
- Recommends methods to improve network provider compliance to
health plan QI Program policies and procedures, including
profiles/scorecards and efforts to increase provider compliance to
practice guidelines, such as through medical record review.
- Fields annual member and provider satisfaction surveys, working
with vendor to clarify results and present findings and
recommendations to senior leadership.
- Assists with efforts to secure successful NCQA
- Performs activities to comply with annual HEDIS data collection
and analysis, preparing recommendations to increase rates as
- Participate in site visit preparation and execution by various
regulatory and accreditation agencies (DCH, DHR, CMS, EQRO).
- Monitors and tracks all state and federal quality improvement
and reporting requirements.
- Supports efforts to submit monthly, quarterly, semi-annual, and
annual regulatory required performance reports.
- Assists in developing short range plans for overall area
- Develops and oversees the implementation of programs and
- Acts in liaison capacity with other areas and business
- Makes recommendations on matters of policy in area of
- Performs other duties as assigned. Additional Responsibilities:
- Required A Bachelor's Degree in nursing or a related health
field or equivalent years of related experience
- Preferred A Master's Degree in nursing, business or a related
field - replaces 3 years of experience Candidate Experience:
- Required 5 years of experience in a health care delivery
organization, such as a managed care organization or a hospital
- Required 3 years of experience in QI, performing a wide range
of functions with strong focus on data analysis and initiation of
improvement initiatives that resulted in desired outcome
- Required 3 years of experience in process improvement and
- Required Other Knowledge of Medicaid and/or Medicare programs
- Intermediate Ability to work in a fast paced environment with
- Intermediate Demonstrated organizational skills
- Intermediate Ability to multi-task
- Intermediate Other Knowledgeable of current trends in quality
improvement in managed health care
- Intermediate Other Knowledgeable of DCH, DHR and CMS regulatory
- Intermediate Other Knowledgeable of JCAHO, NCQA, HEDIS and
- Intermediate Other Ability and confidence to make decisions
based on scope of the job
- Intermediate Other Ability to work on multiple projects and
tasks on a daily basis, remaining calm under pressure
- Intermediate Other Ability to be flexible in the face of
- Intermediate Other Ability to work effectively across
departmental lines Licenses and Certifications:
A license in one of the following is required:
- Preferred Licensed Registered Nurse (RN)
- Required Other Appropriate state licensure Technical Skills:
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Visio
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook Languages:
About usHeadquartered in Tampa, Fla.,
WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on
providing government-sponsored managed care services to families,
children, seniors and individuals with complex medical needs
primarily through Medicaid, Medicare Advantage and Medicare
Prescription Drug Plans, as well as individuals in the Health
Insurance Marketplace. WellCare serves approximately 5.5 million
members nationwide as of September 30, 2018. WellCare is a Fortune
500 company that employs nearly 12,000 associates across the
country and was ranked a "World's Most Admired Company" in 2018 by
Fortune magazine. For more information about WellCare, please visit
the company's website at . EOE: All qualified applicants shall
receive consideration for employment without regard to race, color,
religion, creed, age, sex, pregnancy, veteran status, marital
status, sexual orientation, gender identity or expression, national
origin, ancestry, disability, genetic information, childbirth or
related medical condition or other legally protected basis
protected by applicable federal or state law except where a bona
fide occupational qualification applies. Comprehensive Health
Management, Inc. is an equal opportunity employer,
Keywords: Wellcare, Newark , QI Project Manager, Sr, Executive , Newark, New Jersey
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