Clinical Specialist, Quality Management & Performance

Overview

Now is the Time to Join Us!

Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Responsibilities

Who are you?

 

Responsible for overseeing quality systems and regulatory compliance within state, federal, and accreditation bodies. Through standard operating procedure review and internal audits, they are responsible for identifying discrepancies, ensuring adherence to clinical policies, and safeguarding the reliability of clinical data. They collaborate closely with clinical teams, regulatory bodies, and accreditors. The specialist’s focus is continuous clinical improvement and regulatory excellence.

 

In this role you will wear many hats, but your knowledge will be essential in the following:  

• Ensures compliance with state, federal, NCQA, and URAC standards.
• Conduct internal and external audits of clinical programs.
• Prepare and present quality assurance reports
• Monitor clinical trial activities to ensure adherence to protocols
• Train clinical staff on regulatory requirements and quality standards
• Assists with staff training materials and software development to ensure use of up-to-date evidence-based resources.
• Identify and manage risks related to clinical quality
• Review and approve Standard Operating Procedures
• Collaborate with cross-functional teams to resolve quality issues
• Maintain up-to-date knowledge of industry standards and regulations
• Stay current with evidence-based practice models and current processes to provide staff instruction.
• Other related duties as assigned to meet departmental and Company objectives
• Attend and participate in all mandatory department and training meetings as assigned by management.
• Comfort level in Microsoft suite and Smart Sheet
• Participates in case file preparation and mark-up for audit
• Ability to pass external audits to include URAC and NCQA.
• Maintain HIPPA compliance per company’s policy and procedures.
• Maintain confidentiality and minimum requirement rules.
• Complete all required yearly training per company’s expected period.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Qualifications

What you bring to the Personify Health team:

 

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including:

• Holds an active unrestricted Registered Nursing License
• Bachelor’s Degree preferred
• 2-4 years UR, CM, DM experience required
• Managed care experience preferred

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

• Basic computer literacy
• Excellent analytical and problem-solving skills
• Exceptional attention to detail
• The ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills
• Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Ability to work independently and utilize written resources to problem solve.
• After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in:
• Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet—there may be additional programs as it relates to particular job duties
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Excellent verbal and written communication skills for upward and downward conversations

No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you!

 

Personify Health is an equal opportunity organiza