Senior Clinical Quality Performance Specialist

Role Overview: The Senior Clinical Quality Performance Specialist is responsible for overseeing, designing, and implementing quality initiatives, identifying root causes, establishing and executing work plans to implement effective interventions. The position is grounded in data analytics skills in order to work collaboratively with providers, members, and internal departments across the organization to conduct ongoing processes that identify opportunities for quality, service, and clinical improvement. Manages activities related to plan accreditation, preventive health improvement, business analysis, and clinical and service quality improvement, including state withholds, Healthcare Effectiveness Data and Information Set (HEDIS), and Consumer Assessment of Healthcare Providers and Systems (CAHPS). Also supports the organization’s quality improvement philosophy and promotes the use of quality improvement (QI) tools in decision-making.

Work Arrangement

• Remote - This position is fully remote; however, the associate must work during Eastern Standard Time (EST) hours.
  
  

Responsibilities

• Provide key data analysis and critical thinking for the development and assessment of quality improvement project interventions.
• Develop reports and analyses, and present findings to the Quality Committee for input and direction.
• Support HEDIS and Clinical Practice Guidelines.
• Support accreditation activities and clinical quality performance improvement initiatives.
• Perform ad-hoc analyses of underperforming processes by collaborating with Subject Matter Experts (SME) and internal stakeholders to define current processes and recommend improvements.
• Remove barriers to ensure the successful completion of strategic quality projects.
• Conduct analyses and provide summary reports to senior management.
• Act as a primary liaison to internal departments requiring collaboration and coordination.
• Support the development of new and existing staff by identifying learning and training opportunities.
• Serve as a mentor to new hires, ensuring consistency in information and training.
  
  

Education & Experience

• Associate’s Degree or equivalent work experience required.
• Registered Nurse (RN) required.
• 5 years of experience in clinical or service quality improvement required.
• 5 years of experience in managed care required.
• Unrestricted Registered Nurse license in the plan’s state or any state in which the individual works.
• Experience working within a managed care plan organization
• Intermediate or expert level user of Microsoft Excel/SAS
• Experience managing National Committee of Quality Assurance (NCQA) accreditation surveys preferred.
• Knowledge and understanding of quality improvement functions within a Managed Care Organization (MCO) preferred.
• Prior experience with project facilitation and/or project management preferred.
  
  

Skills & Abilities

• Proficient in Microsoft Excel or other data tools.
• Excellent written and verbal communication skills.
• Strong organizational, analytical, and interpersonal skills.
• Ability to work effectively across all levels of the organization.
• Ability to design, develop, and implement projects addressing financial, quality, and service improvements.