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Work in Quality Management - handle appeals/grievances for the plan
Provides consultative services and manages quality improvement activities and initiatives for RiverSpring Health Plans. Analyzes performance and recommends improvement initiatives and/or corrective actions. Utilizes quality improvement framework, Plan, Do, Study, Act, to facilitate rapid cycle improvement strategies. Serves as a resource to quality improvement committees and work groups. Integrates compliance and regulatory requirements into quality improvement processes. Works under general direction.
1.Collaborates with clinical management to identify, develop and implement quality improvement standards and criteria that meet program goals. Evaluates effectiveness of standards and recommends changes, as needed.
2. Establishes and communicates protocols and standards of
care for a cultural and demographic diverse patient/member population; provides intervention guidelines based on these population health needs.
3. Coaches and facilitates performance improvement activities designed to help teams and programs meet and exceed quality scorecard indicators. Instructs management and staff in the meaning and use of data for the purpose of assessing and improving quality.
4. Participates in the development of standards and criteria for monitoring compliance with Federal and State regulatory requirements and RiverSpring Health Plans performance standards of care. Develops performance measures and data collection instruments.
5. Facilitates quality assurance and utilization review activities with interdisciplinary teams on ways to improve and positively affect the care that is provided to patients/members. Reviews and analyzes changes in the health status and outcomes of patients/members utilizing outcomes data. Consults and collaborates with clinical staff to identify trends and opportunities for improvement in health status and outcomes.
6. Collaborates with stakeholders in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies.
7. Investigates patient/member related appeal, complaints and quality of care (QOC) issues, incidents, and serious adverse reportable events in collaboration with internal staff and providers. Performs utilization and quality assessment review; identifies and analyzes results; prepares investigation summary report; and creates/implements corrective action plan as appropriate. Provides education about identified quality trends, outcomes of reviews and new requirements.
8. Follows-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.
9. Conducts audits of patient/member case records. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology.
10. Keeps informed of the latest internal and external issues and trends in utilization and quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies and procedures to address these trends.
11. Performs onsite medical record reviews for HEDIS or other related compliance or quality improvement initiatives.
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