Job Description
- Job Description:
- Evaluates, analyzes and monitors staff or provider performance to achieve excellence in quality
- Provides timely, relevant, accurate, and objective feedback to staff, providers, and the management team which includes a plan of action or recommendations when deficiencies are identified
- Acts as technical resource and develops learning solutions that engage the learner and produces desired business goals and objectives
- Performs quality audits of staff/providers to ensure compliance with departmental plans and regulates policies and procedures
- Assists in designing effective learning solutions based on analysis of quality audit results when quality deficiencies are identified
- Monitors and reports on individual and department results to include benchmarking and trending
- Acts as a day-to-day resource for technical assistance and clinical decision making
- Provides guidance with interpretation of clinical aspects of Corporate Medical Policy and other clinical guidelines to assist in making medical decisions
- Aligns clinical decision-making processes with regulatory requirements (e.g. DOI/ERISA/NCQA)
- Keeps abreast of medical knowledge, care patterns, regulatory and governmental rules and regulations
- Works with management team to support decisions on workflow process, quality improvement, goal setting and data driven information-based decision-making
- Provides timely feedback to management on staff/provider performance
- Acts to facilitate change efforts and promote department, division and corporate goals
- Assist with maintenance of Web Content Management System (WCMS) and may collaborate with other areas to maintain SOP’s
- Assists staff with resetting of passwords and set up of new users for vendor electronic messaging
- Requirements:
- RN with 3 years of clinical experience or LPN with 5 years of clinical experience required
- Must have previous work experience in applicable business area (i.e. UM, CM, Medical Review or quality programs)
- Bachelor's degree or advanced degree preferred
- Benefits:
- Medical, dental, and vision coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for continued education
- 401k match including an annual company contribution
- Work-life balance, flexibility, and the autonomy to do great work
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