Enterprise Clinical Quality Analyst II

Job Summary:

The Enterprise Clinical Quality Analyst is responsible for reviewing, tracking and trending QI and grievance issues for all programs and in all states in addition to prep work for Quality Executive Committee (QEC)

Essential Functions:

• Review, track and trend QI and grievance issues for all programs and in all states in addition to prep work for Quality Executive Committee (QEC)
• Maintain reports for QI trends and metrics, as well as prepare reports for Delegation Oversight
• Ensure all clinical quality issues are resolved within specified timeframes as indicated by the states served and programs therein, CMS and all accrediting entities
• Perform reviews, tracking and trending of Potential Member Risk (PMR) cases, referring appropriate cases to Fraud & Abuse and preparing reports for presentation to senior management
• Review and maintain compliance of Quality Improvement policies with NCQA standards
• Maintain case files for all Quality of Care (QOC) issues
• Assist management with annual Encounter Data Validation (EDV) studies
• Request medical records, review documentation and assign a severity level to each Quality of Care case or forward to appropriate medical/dental/specialty reviewer
• Maintain SharePoint database of QOC cases
• Appropriately refer QOC cases to Fraud & Abuse
• Act as liaison with the Case Management and Behavioral Health
• Develop materials and provide education on the reporting of Quality of Care Grievances and Sentinel Events to other appropriate departments within CareSource
• Function as a resource for educating and resolving questions related to documentation requirements for QOC issues
• Assist the Provider Relations staff with corrective action plans (CAPs) for affected providers
• Review QOC cases, as needed, with the Medical Director/Chief Medical Officer (CMO) and carry out actions as indicated by the CMO
• Maintain accurate individual Excel spreadsheet, showing the status of each open QOC case
• Track and monitor provider QI issues for monthly reporting of provider re-credentialing to Network Operations
• Perform External Quality Review (EQR) record retrieval, research record and review
• Conduct performance improvement studies for various areas
• Assist in the development of work plans and measurement strategies including those of other departments
• Perform any other job duties as requested

Education and Experience:

• Associate of Science in Nursing is required
• Bachelor of Science Degree in Nursing (BSN) is preferred
• Minimum of three (3) years clinical experience as an RN is required
• Minimum of one (1) year of Managed Care experience preferred
• NCQA experience preferred

Competencies, Knowledge and Skills:

• Proficiency in Microsoft Excel, Access and Word
• Knowledge of NCQA standards
• Familiarity with SharePoint preferred
• Strong written and verbal communication skills
• Ability to work independently and within a team environment
• Familiarity of the healthcare field
• Knowledge of Medicaid and Medicare
• Effective listening and critical thinking skills
• Strong interpersonal skills and high level of professionalism
• Effective problem solving skills with attention to detail
• Ability to develop, prioritize and accomplish goals
• Customer service oriented
• Analytical and organizational skills

Licensure and Certification:

• Current, unrestricted Registered Nurse (RN) licensure in state of practice required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.