Job Description
Job Summary:
Job Summary:
Enterprise Clinical Quality Specialist III is responsible for performing quality monitoring activities of clinical and non-clinical areas for compliance with National Committee for Quality Assurance (NCQA) and identified State and Federal requirements.
Essential Functions:
Responsible for monitoring activities via Guiding Care, OnBase, Streamline, Facets, MHK, and CareSource policy and procedures
Assist in identifying and evaluating the organizations risk areas related to accreditation, state and federal requirements and provide input to effectively communicate evaluation and recommendations to management
Responsible for conducting independent random and scheduled monitoring activities for departments associated with NCQA. Additionally, responsible for monitoring of some state and federal requirements
Analyze the quality assurance results and make recommendations for corrective action when problems are identified
Provide feedback to all associated departments with quality monitoring variances and document corrective action and follow up
Provide documentation for discussion at meetings and prepare minutes with follow-up action items
Prepare statistical reports outlining departmental error rates/trends monthly for review
Responsible for follow-up on designated case and file review findings
Functions as a resource for business and clinical personnel in resolving questions related to documentation requirements and quality monitoring activities
Responsible for ongoing educational programs and individual education within all departments that have quality monitoring requirements related to accreditation, state and federal requirements
Assist in preparing cases/files for NCQA Onsite Survey file reviews
Perform any other job duties as requested
Education and Experience:
Completion of an accredited Registered Nurse (RN) degree program is required
A minimum of three (3) years of clinical experience is required
Minimum of three (3) years of managed care experience is preferred
Experience in case management, managed care, or utilization review is preferred
Experience in quality improvement and/or auditing is preferred
Accreditation experience is preferred
Competencies, Knowledge and Skills:
Microsoft office proficiency and/or Guiding Care proficiency
Knowledge of NCQA
Quality improvement process and analysis skills
Strong people/interpersonal skills
Strong organizational, problem solving and decision-making skills
Ability to work on multiple projects
Excellent oral and written communication skills
Strong attention to detail
Licensure and Certification:
Current, unrestricted Registered Nurse (RN) licensure is required in state of practice
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type:
Salary
Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.
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CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law.
