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Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Quality Improvement Specialist - On Call, Rockville Regional Offices

Location: Rockville, MD Additional Locations:
Job Number: 763274 Date posted: 01/08/2019

Identifies monitors, evaluates, coordinates, supports and reports relevant information/data related to assessment of quality of care issues, regulatory or compliance issues, member complaints, and peer or case review findings to the Executive Director and/or appropriate department designee or Regional Quality Improvement Committee.

Essential Responsibilities:

  • Implements quality review processes for quality complaints, referrals, peer review, regulatory or compliance concerns, etc. by investigating cases received by the Quality Management Department, either through referrals, other departments, case review or other mechanisms.

  • Monitors and screens cases for quality concerns or issues related to quality improvement processes.

  • Identifies and collects appropriate data; incorporates quality improvement tools and methodology in all assignments.

  • Provides staff support for quality improvement activities on a regional or a departmental level.

  • Works closely and collaboratively with the Quality Management leadership on accreditation preparation, peer review oversight, committee support and other quality projects, as needed.

  • Acts as a liaison and facilitator for quality reports related to database tracking, quality trends and analysis, and specific focused studies, as assigned.

  • Develops and maintains quality management systems, standards and criteria for reporting aggregate data and focused review findings and results in collaboration with the Quality Management Leadership, medical group, and other designated departments.

  • Demonstrates familiarity with practitioner peer review methods to facilitate the process of unbiased case review with strict adherence to confidentiality and protection of sensitive information and findings.

  • Establishes and maintains key linkages between the Integrated Delivery System, Risk Management and Peer Review.

  • Advances the quality and service improvement priorities of the region by using a variety of quality strategies, tools and techniques.

  • Performs other duties as directed.
  • Position temporary for completion of HEDIS project
    Basic Qualifications:
  • Minimum seven (7) years of experience in Managed Care/HMO or equivalent health care experience required.
  • Minimum three (3) years of experience in quality or other related areas of practice required.
  • Education
  • Bachelor's degree in a healthcare related field required.
  • License, Certification, Registration
  • N/A

  • Additional Requirements:
  • Experience in quality improvement activities with ability to work as a consultant, facilitator, and colleague with other Quality Management staff, physicians and KP staff at all levels of the organization required.
  • Previous case review or quality assessment experience required.
  • Knowledge and/or experience with NCQA, AAAHC, state and federal regulations required.
  • Excellent written and verbal communication skills.
  • Excellent interpersonal skills.
  • Self motivation.
  • Ability to work independently with minimal supervision.
  • Strong computer skills and use of databases required.

  • Preferred Qualifications:
  • Professional Clinical License, such as: Register Nurse, Social Worker, Pharmacist, Therapist (Respiratory, Occupational, Physical, and Medical Technology) strongly preferred.
  • Master's degree preferred.
  • HEDIS Extraction experience preferred.
  • EPIC - Health Connect Electronic Medical Record experience preferred.
  • Primary Location: Maryland,Rockville,Rockville Regional Offices 2101 E. Jefferson St. Scheduled Weekly Hours: 1 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun Working Hours Start: Varies Working Hours End: Varies Job Schedule: Call-in/On-Call Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Non-Union, Non-Exempt Job Level: Individual Contributor Job Category: QA / UR / Case Management Department: Quality Improvement Specialist Travel: No

    About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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