Reporting to the Manager of Quality & Accreditation, the Quality & Accreditation Specialist supports organization-wide quality improvement initiatives related to compliance with standards of care and delivery of quality services. This role is crucial for maintaining our National Committee for Quality Assurance (NCQA) accreditation, Health Effectiveness Data and Information Set (HEDIS), Member/provider complaint trending and response coordination, Member experience survey coordination with trend summary and other organization-wide quality improvement initiatives.
- Serve as a clinical subject matter expert in NCQA health plan standards and survey preparedness.
- Maintains expert knowledge in NCQA standards and a strong working knowledge of standards, and applicable state and federal regulations, health plan benefits, credentialing and network design.
- Coordinates the preparation, auditing, and submission of all relevant data for NCQA survey, HEDIS, CAHPS, etc.
- HEDIS
- Maintains a strong working knowledge of HEDIS specifications and supports during peak season.
- Effective and efficient health plan quality assurance & accreditation management in accordance with NCQA Standards, State and Federal regulations.
- Conducts assessment of internal performances against standards, performs quantitative and qualitative analysis in compliance with NCQA Standards.
- Monitors and analyzes data related to healthcare quality and performance, identifying and acting on areas for improvement.
- Develops and implements quality improvement initiatives to enhance the delivery of health care services and collaboration with network providers.
- Proposes and enacts corrective action plans, policy and workflow revisions and QI performance improvement projects/initiatives to improve Member outcomes.
- Ability to leverage data to create visualizations and presentations that effectively communicate trends, insights, and strategies to internal stakeholders and leadership teams.
- Health Plan Accreditation, NCQA related experience or the equivalent combination of training and experience is required.
- Healthcare Effectiveness Data and Information Set (HEDIS) experience, preferred.
- Must foster a culture of continuous quality improvement.
- Able to work independently, with team and cross functionally with minimal supervision.
- Appreciation of cultural diversity and sensitivity towards individual preferences and needs of Member population.
- Proficient in English with verbal, written, interpersonal and public communications.
- Proficient with Microsoft Office products, typing, and ability to maintain accurate clinical documentation; Excel, including the use of formulas, pivot tables, and data visualization tools; proficient in creating slides using Microsoft
PowerPoint.
- Ability to maintain production levels and quality standards with minimal supervision.
Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:
- Respectful, open communication and cooperation between all employees.