Careers in Quality

Leads large scale quality improvement program initiatives and major health outcomes improvement projects. Actively researches and develops interventions that can be used to improve performance and clinical quality and support HEDIS, clinical measures and the NCQA accreditation process. Identifies, leads and facilitates performance improvement projects and initiatives, measurement and analysis for managed care programs, processes, and outcomes. Develops and writes business cases and quality improvement plans, charters, and reports. Builds a dynamic culture of patient safety by developing and leading clinical aspects of the Quality of Care (QOC) process. Engages with healthcare teams in the development and adoption of QI frameworks, performance improvement around nationally endorsed quality measures (NQF, NCQA, CMS), and strategy development that drives a culture of continuous quality improvement, by leveraging those relationships.

• Quality Monitoring and Improvement: Leads large scale quality improvement program initiatives and major health outcomes improvement projects, facilitates continuous departmental (divisional) process projects and quality improvement activities to measurably improve the health of the members we serve.  Evaluates data needs and collaborates with Health Statistical Analytic Department and other analytics teams to identify opportunities which support departmental and divisional goals.  Designs, develops and implements solutions which address the identified opportunity. Assists others within the Quality Management Department in study design, planning for data collection, root cause analysis and implementing solutions.
• Performance and Improvement Initiatives: Conducts audits that supports regulatory and accreditation requirements, including audits of external vendors and delegates, internal processes and clinical measures, such as HEDIS.  Assesses, reviews, and educates internal and external customers regarding the quality of care and services provided to their members through on-site assessments and data analyses.  Serves as a subject matter expert consulting with external representatives including provider office staff and delegates. Provides assistance with the design, development and implementation of solutions which address opportunities identified by provider data or IHS staff for improvement.
• Research: Designs quality improvement initiatives/studies based on sound performance improvement principles, tools and statistical methodologies. Develops major quality improvement activities and programs that encompass research, study design, population and outcome analysis.  Consults with internal and external resources to keep study design and implementation directed to address study questions or charters.  Leads multidisciplinary efforts to develop health management programs and clinical guidelines designed to improve quality of care. Optimizes use of existing divisional and corporate information resources.
• Accreditation performance and regulatory performance measurements: Reviews documentation for compliance; audits processes; interviews appropriate management, and staff; assists with gap analysis and the development and monitoring of corrective action plans.  Serves as a resource to staff and delegates seeking to better understand the accreditation/regulatory agency standards and aids in the development of internal action plans to assist others in development of processes and protocols within their department.
• Annual Quality Review and Development of Work Plan: Participates in the annual update of quality improvement (QI) program description and QI work plan. Assists with the evaluation of the effectiveness of the QI program and its related improvement projects, as well as identification of performance improvement opportunities.
• Report Development: Develops and writes performance improvement plans in accordance with accreditation requirements.  Collaborates and authors business cases for department initiatives.  Reviews and edits documents which will be utilized both internal and external audiences.
• Quality of Care: Coordinates the Quality of Care process by reviewing weekly concurrent review reports and ensuring other QOC referrals are appropriately screened and processed. Facilitates the thorough investigation of potential QOC concerns and the Peer Review Committee alongside the medical directors. Continues to develop and monitors the “Track and Trend” database for effective reporting to appropriate committees.
• Value Based Programs: Works closely with the Value Based team to provide the necessary framework for quality measurement and performance improvement, in partnership with Network Management and Contracting departments. Serves as a SME to the VBP team on issues related to clinical quality and program development. Regularly appraises and updates relevant quality measures and benchmarks to align with the overall Blue KC Value-Based strategy
• Committee Management: Manages and collaborates with committees related to clinical quality, performance improvement and accreditation requirements such as the Peer Review, Fraud Waste and Abuse, Corporate Credentialing, Clinical Steering, Health and Behavior, and Delegated Oversight. Manages relevant workplans, agenda management, meeting minutes and follow-up items. Explores new opportunities for continuous quality improvement through these committees.
• Project Management: Works on seasonal quality related projects as required, such as Blue KC clinical outcomes grant awards, business cases, contract reviews, SWOT analysis of the QI program, Healthcare Quality week, team engagement projects, etc.

Minimum Qualifications

• Registered Nurse with Licensure in Missouri and Kansas
• 5 years of previous clinical experience in primary care, specialty, or acute care setting
• Bachelor’s Degree from a college or university in clinical discipline or any combination of education and experience providing the types and levels of knowledge, skills, and abilities required by the job
• 4 years’ experience in a healthcare-related organizational assessment (auditing) for regulatory and accreditation compliance, and in clinical quality improvement, conducting and documenting performance improvement initiatives to address accrediting and regulatory bodies, and clinical and service quality program management
• Demonstrated experience in design and implementation of large scale quality improvement projects.
• Intermediate level of knowledge of statistical methodology and application
• Advanced knowledge of organizational assessments for compliance against accreditation and regulatory requirements
• Advanced knowledge of medical terminology; health plan HEDIS and CAHPS; NCQA Health Plan standards; and URAC health UM and Case Management standards.
• Knowledge of quality improvement principles and project management, including formal training or certification and proven experience leading relevant business process improvement projects and/or quality improvement projects or teams.

Preferred Qualifications

• Master’s Degree in Healthcare Administration, Business or Statistics
• Intermediate level knowledge of health plan data HEDIS, NCQA, and CAHPS.
• Ability to use basic quality improvement tools and techniques such as value stream mapping, hypothesis testing, cause and effect analysis and FMEA.
• Intermediate level knowledge of Microsoft Office Access application
• Preferred certifications include: CPHQ or equivalent healthcare QI, Lean/Six Sigma, PMP or equivalent project management