Quality Perform Specialist Clinical

Quality Performance Specialist - Clinical • As part of the Quality Management team, the Quality Performance Specialist - Clinical is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing standards of care. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines. The position also supports accreditation and clinical quality performance improvement activities. Responsibilities: • Assist with accreditation and clinical quality performance improvement initiatives. • Conduct quality-of-care reviews, including sentinel events and member concerns; collaborate with physician advisors and clinical quality committees. • Collect and organize necessary medical records for clinical review; summarize findings for committee review. • Prepare and manage Quality Assessment and Performance Improvement (QAPI) meeting materials, including packets, schedules, agendas, and minutes. • Review and approve the annual Quality Management (QM) work plan, including performance measures, goals, objectives, and thresholds. • Recommend new or improved QM activities using Plan-Do-Study-Act (PDSA) cycles. • Develop quarterly Quality of Care (QOC) trending reports for QAPI and follow up on recommendations. • Ensure compliance with QM policies, including annual reviews, updates, and approvals. • Participate in activities and reporting to maintain compliance with state regulations and NCQA standards. • Collaborate with the Quality Improvement Department on annual medical record review activities, including tool development, staff training, testing, and auditing. • Perform other duties as assigned. Education & Experience: • Associate's Degree or equivalent experience required; Bachelor's Degree preferred. • Minimum 3 years of experience in clinical or service quality improvement, healthcare delivery, or related field. • Active, unrestricted clinical license (RN) • Prior experience in project facilitation or management preferred. • Knowledge of Quality Improvement (QI) functions in a Managed Care Organization (MCO) preferred. • Familiarity with Medicaid and Medicare programs preferred. • Proficiency in Microsoft Office Suite (Word, PowerPoint, Excel) required. Our Comprehensive Benefits Package: We offer flexible work solutions, including remote options and hybrid schedules, competitive pay, paid time off (including holidays and volunteer events), health insurance coverage for you and your dependents starting Day 1, 401(k), tuition reimbursement, and more. About AmeriHealth Caritas: Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact millions of lives through our national footprint of products, services, and award-winning programs. Headquarters in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmacy benefit management, specialty pharmacy services, behavioral health services, and other administrative solutions. Discover more about us at www.amerihealthcaritas.com Apply tot his job