What is your impact?
The Clinical Quality Improvement Specialist performs quality assessments for physicians, facility, and ancillary providers considering all available information internal and external to the organization. Collaborates with internal staff and network management to define potential quality improvement activities within the corporation, at the individual or group practitioner level; facility level or network system level and could potentially involve a third party in the collaboration. Leads the full spectrum of various quality improvement initiatives to include collaboration with key stakeholders (both internal and external) for design, implementation, monitoring, and relationship management.
This is FEP-dedicated and a member of the FEP Quality team
Supports HEDIS initiatives, medical record chart chases, and conducts telephonic outreach guided by scripts as needed. Educates Members to obtain preventive screenings needed to close a specific HEDIS care gap and/or assist with obtaining a primary care provider. Monitors, tracks, and reports on HEDIS initiatives as assigned by Manager or Medical Director. Participates on or leads departmental projects or components of projects. May plan, organize, monitor, and control projects to ensure the effective use of resources and adherence to project management standards and reporting requirements. Uses computerized systems for tracking, information gathering, and troubleshooting. Documents in required systems: FEPDirect, Quest, FEP Risk Tool, Excel, and other systems as needed.
What are your key responsibilities?
- Provide leadership where an opportunity for quality improvement activities is determined with network representatives and/or other key stakeholders to exist.
- Design, implement and monitor the initiative. These opportunities could potentially involve internal personnel, individual or a group of physicians, a hospital or hospital system, ancillary provider or other delivery system entity and has the potential to involve a third party.
- Perform clinical quality assessment analysis to include all available information that comes from internal and external sources to include claims and other internal data, customer inquiries, peer review findings, publicly available data, industry information and others and provide findings to key stakeholders.
- Perform medical chart reviews where necessary to support improvement and compliance related activities.
- Manage the relationship with all involved parties.
What is required:
- 4+ years related work experience. Experience Details: Health care and/or insurance industry
- Related Bachelor’s degree or additional related equivalent work experience
- RN – Registered Nurse – State Licensure And/Or Compact State Licensure
- Demonstrates a high degree of initiative, able to work and follow through on assignments without close supervision
- Proven strong project management skills
- Superior written and verbal communication skills needed as well as strong interpersonal, organization and problem-solving skills.
- Proactive approach to identifying opportunities for quality improvements
What is preferred:
- Green Belt of six sigma process or willing to obtain
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
- Medical, dental, vision, life and global travel health insurance;
- Income protection benefits: life insurance, Short- and long-term disability programs;
- Leave programs to support personal circumstances;
- Retirement Savings Plan includes employer contribution and employer match;
- Paid time off, volunteer time off, and 11 holidays
- Additional voluntary benefits available; and
- A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range: $66,400 – $107,900
Typical Annualized Hiring Range: $66,400 – $83,000
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.
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