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GENERAL SUMMARY
Responsible for the research and identification of quality of care issues to ensure compliance with Coventry’s quality improvement programs as well as accreditation and regulatory standards.
ESSENTIAL RESPONSIBILITIES
- Effectiveness Data and Information Set (HEDIS) results, appeals, etc.
- Maintains accurate documentation of all quality improvement activ
- Effectiveness Data and Information Set (HEDIS) results, appeals, etc.
- Maintains accurate documentation of all quality improvement activ
- Performs quality improvement studies as they relate to trends identified via utilization review activities, utilization patterns, audits, Healthcare ities, i.e., studies, surveys, audits, peer reviews, etc. Performs analysis and provides oversight for delegated functions.
- Identifies possible quality of care issues through research and data analysis. Prepares and distributes accurate and timely reports according to department policies, documentation standards, and regulatory requirements.
- Under the direction of assigned Medical Directors and quality improvement management, conducts audits to research quality of care issues.
- Assists in conducting peer review chart audits, compiling statistics, and reporting results to the appropriate oversight committees.
- Monitors and assures that follow-up re-evaluation activities take place when deficiencies are identified and recommendations for corrective action have been made.
- Develops and provides training to members and employer groups regarding preventive health and wellness as they relate to trends identified via review activities and audits.
- Assists in preparing the annual quality improvement program evaluation and work plan.
- May complete an annual review of department policies and procedures and make recommendations for updates based on changing needs or trends.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Licensed Practical Nurse (LPN) or Registered Nurse (RN) with active state license required.
- Complies with all state certification requirements in the state where job duties are performed.
- Previous (2-4 years) clinical experience required.
- Previous quality improvement and/or managed health care experience preferred.
- Fundamental knowledge of relevant legal, medical, and regulatory terms, issues, and practices.
- Excellent verbal and written communication skills.
- Demonstrated data analysis and report preparation skills.
- Knowledge of standard software packages required, including Word, Excel, and Powerpoint.
- Valid driver’s license may be required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: , , US
Organization: 15000 - CHC of Delaware
Schedule: Full-time
Job Posting: 2013-02-07 00:00:00.0
Job ID: 1310451