Highmark Health Sr. Clinical Quality Management Consultant in Pittsburgh, Pennsylvania
This job works with appropriate departments, in the areas of compliance and process improvement, for all product lines.The incumbent 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.
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.
- Bachelors Degree in Nursing with current state license or Bachelor's Degree in other clinical field such as Physical Therapy or Social Work, or Psychology
- Master’s Degree
10 - 15 years of related progress experience in the area of specialization including experience in leading large projects
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.
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
LICENSES AND CERTIFICATIONS
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
Language (Other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Does Not Apply
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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled