Highmark Health Sr. Clinical Quality Management Consultant in Pittsburgh, Pennsylvania

Description

JOB SUMMARY

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.

ESSENTIAL RESPONSIBILITIES

  • 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.

EDUCATION

Required

  • 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

Substitutions

  • None

Preferred

  • Master’s Degree

EXPERIENCE

Required

  • 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.

Preferred

  • 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

Required

  • None

Preferred

  • None

SKILLS

  • 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)

None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Rarely

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

Yes

Lifting: up to 10 pounds

Occasionally

Lifting: 10 to 25 pounds

Rarely

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.

REQNUMBER: J124958

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled