Market Clinical Quality Specialist II

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct thorough reviews of assigned cases/files to ensure compliance with regulatory standards and Standard Operating Procedures (SOPs).

• Execute monthly monitoring for inter-rater reliability of case evaluations.

• Recognize opportunities for training and development, collaborating with colleagues and Care Management to create educational programs.

• Assist management in compiling reports on case reviews at both aggregate and individual contributor levels.

• Act as a subject matter expert in designated areas.

• Engage in interdepartmental meetings and workgroups focused on Care Management processes.

• Offer cross-functional support for monitoring, accreditation, and operational duties.

• Stay informed about relevant Federal and State Requirements, including responsibilities associated with the Corporate Integrity Agreement.

• Track regulatory updates, identify affected areas, communicate changes, and aid in their implementation.

• Seek out best practices and improvement opportunities in health services monitoring and accreditation.

• Facilitate the rollout of improvement initiatives.

• Carry out additional job-related tasks as instructed.

⛳️ Requirements

• An Associate of Science in Nursing (ASN) is mandatory.

• A minimum of one to three (1 to 3) years of experience in Quality Improvement, Project Management, Case Management, or Utilization Review is essential.

• A current, unrestricted Registered Nurse (RN) license in the state of practice is required.

• A Bachelor of Science in Nursing (BSN) is preferred.

• At least three (3) years of varied clinical experience as an RN is preferred.

• Proficiency in Microsoft Excel, Access, and Word at an intermediate level is necessary.

• Intermediate skills in SharePoint are required.

• Knowledge of PowerPoint and Visio is preferred.

• Strong written and verbal communication abilities are essential.

• Capability to work both independently and collaboratively within a team setting is needed.

• Familiarity with the healthcare industry is important.

• Understanding of Medicaid and Medicare regulations is necessary.

• Effective listening and critical thinking skills are required.

• Strong interpersonal skills and a high degree of professionalism are essential.

• Excellent problem-solving abilities with meticulous attention to detail are necessary.

• Ability to set, prioritize, and achieve goals is important.

• Technical writing skills are required.

• Proficient in coordinating complex projects and multiple meetings is essential.

• Ability to collaborate with various disciplines and staff levels across departments is necessary.

• Case Management Certification, such as Certified Case Manager (CCM), is highly preferred.

🏝️ Benefits

• A bonus tied to company and individual performance may be available.

• A comprehensive total rewards package is offered.

• Support for overall employee well-being is provided.