AmeriHealth Caritas Quality Perform Specialist Clinical, RN in Newark, Delaware
Quality Perform Specialist Clinical, RN
AmeriHealth Caritas Delaware is excited to have been chosen as one of the Medicaid managed care plans for the Diamond State Health Plan and Diamond State Health Plan- Plus programs. Backed by a national organization, we have long-term experience serving the Medicaid population in neighboring states. We are committed to delivering health care through innovative services and programs and are looking forward to helping Delaware become an even healthier state.
Responsible for leading and coordinating the clinical quality review process of medical records utilizing care standards. Responsibility include supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines by working collaboratively with the Quality Management Department.
- Assumes responsibility for reviewing all sentinel events and member concerns reported for potential quality of care issues. Coordinates reviews with physician advisors and clinical quality committees as appropriate.
- Assures minimally necessary medical records are collected and organized for clinical review to occur. Summarizes all clinical findings for review by clinical committees as appropriate.
- Prepares meeting packets, schedules meetings, develops agendas, completes minutes, and chairs the Internal Quality Review Committee (IQRC).
- Maintains database to support trending and reporting of adverse outcomes resulting from clinical care provided.
- Develops reports and analysis for semi-annual trending reports and presents to the Quality Medical Management Committee (QMMC) for input and direction. Follows up on any recommendations.
- Maintains QR policies including annual reviews, updates, and approvals.
- Maintains hard copy documentation in accordance with contractual requirements.
- Conducts analysis annually on the Plan’s efforts to improve the safety of members.
- Supports the quality improvement department with annual medical record review activities including HEDIS and Clinical Practice Guidelines by working collaboratively with the Quality Improvement Department. Assistance will be based upon the organizations needs annually but may include participation in the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.
- Performs other related duties and special projects as assigned.
- Bachelor’s degree in health care related field or equivalent preferred.
- RN licensure in state required
- Minimum of 3 years experience in clinical or service quality improvement required
- Minimum of 5 years experience in healthcare delivery required and Managed Healthcare required
- Minimum of 3 years experience in clinical or service quality improvement required.
- Successful management of NCQA accreditation survey preferred.
- Two years managed Medicaid experience preferred.
EOE Minorities/Females/Protected Veterans/Disabled