Clinical Quality Management Consultant

Company :

Highmark Health

Job Description : 

JOB SUMMARY

This job coordinates accreditation and regulatory requirement activities related to performance measurement and outcomes on behalf of the organization. Collaborates with appropriate departments enterprise-wide for all product lines for Quality activities. Serves as a corporate resource, subject matter expert for Quality activities in the areas of compliance and process improvement for all product lines and as representative and collaborator with outside organizations on various performance measurement and outcomes topics/projects. Responsible for managing large projects associated with auditing network provider performance and identification of improvement opportunities through outcome analysis. May perform special studies or audits, clinical guideline development, network provider performance measurement and monitoring, and/or activities to educate or influence the behavior of members or providers. Communicates effectively with customers and colleagues by successfully identifying issues, conducting problem solving resolution and decision making sessions for problems and implementing solutions.   

ESSENTIAL RESPONSIBILITIES

• Develop, oversee and manage large projects targeting members and/or network providers to improve clinical care provided to health plan members, including data analysis; visualizing and resolving complex issues and developing and implementing interventions. Perform review of medical record documentation, practice guideline development and monitoring, network provider performance measurement and monitoring, activities to educate or influence the behavior of members and/or providers, etc.  Perform web base reviews of research, best practices, professional guidelines, health education and any additional resources for clinical analysis purpose.
• Coordinate and monitor the specific quality improvement programs to maintain regulatory compliance and quality accreditation for the corporation.
• Fulfill the role of subject matter expert for the corporation regarding activities related to applicable quality standards and assigned accountabilities. Organize and provide consultative support to relevant corporate stakeholders. Facilitate work-groups on various activities to ensure compliance and implementation of services. 
• Promote a culture of performance excellence by enhancing job skills through quality process improvement and tools training / certification; participating in process and operational initiatives and building and maintaining effective relationships throughout the organization to advance Performance Excellence.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor's Degree in Nursing

Substitutions

• Licensed Registered Nurse with 6 years experience

Preferred

• None

EXPERIENCE

Required

• 3 - 5 years in Nursing
• 1 - 3 years in Quality Improvement
• 1 - 3 years in Research and Development

Preferred

• 1 - 3 years in Cross-Functional Project Teams
• 1 - 3 years in Process Improvement
• 1 - 3 years in Regulatory Compliance

LICENCES AND CERTIFICATIONS

Required

• Registered Nurse

Preferred

• None

SKILLS

• Collaboration
• Continuous Improvement 
• Critical Thinking 
• Written & Oral Presentation Skills 
• Time Management 
• Clinical Research
• Analytical Skills
• Performance Improvement
• Quality Management
• Regulatory Compliance

Language (other than English)

None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Rarely

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Rarely

Lifting: 10 to 25 pounds

Does Not Apply

Lifting: 25 to 50 pounds

Does Not Apply

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and