Clinical Quality Improvement Specialist & Reviewer (RN, LPN, Foreign Medical Graduate)
Company: MetroPlus Health Plan
Posted on: August 4, 2022
Empower. Unite. Care.MetroPlusHealth is committed to empowering
New Yorkers by uniting communities through care. We believe that
Health care is a right, not a privilege. If you have compassion and
a collaborative spirit, work with us. You can come to work being
proud of what you do every day.About NYC Health +
HospitalsMetroPlusHealth 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,
MetroPlusHealth's network includes over 27,000 primary care
providers, specialists and participating clinics. For more than 30
years, MetroPlusHealth has been committed to building strong
relationships with its members and providers to enable New Yorkers
to live their healthiest life. -Position OverviewThe 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 MetroPlusHealth 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
- 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
DOHand 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
- 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
- Create plans/interventions based on barrier, data, and/or
competitor analyses, defined project scope and goals, measurable
metrics for program evaluation 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
- 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
- Statistically significant changes in rates/stratifications
- 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)
- Review provider records against clinical and procedural
- 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
- Implement and monitor provider corrective action plans as
needed. Ensure provider responses are received timely and actions
- 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
- Track and trend clinical quality of care/adverse incidents from
a population perspective and identify opportunities for
- Prepare reports to fulfill CMS reporting requirements for
quality reporting including but not limited to Reportable Adverse
- All other duties as assigned at the discretion of Quality
Management Leadership.Minimum Qualifications
Keywords: MetroPlus Health Plan, Newark , Clinical Quality Improvement Specialist & Reviewer (RN, LPN, Foreign Medical Graduate), Healthcare , Newark, New Jersey
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