• Neighborhood Health Plan
  • $57,440.00 -80,040.00/year*
  • Somerville , MA
  • Scientific Research
  • Full-Time
  • 5 Walnut St

Summary of Position

A career at AllWays Health Partners is you in every way! Inspired by our affiliation with Partners HealthCare, our promise as a people-first organization starts with our employees. Get inspired to bring your unique talents to our diverse community and challenge the health care industry status quo with innovative programs that put people first. Our perks include a competitive benefits package, access to world-class doctors, and more.

The Quality Improvement (QI) Specialist oversees the Quality of Care (QOC) reviews under the direction of the Manager of Quality Improvement (QI) Programs and the Medical Director, as well as provide ongoing project management on all plan-based QI programs. The QI Specialist ensures all projects and QOC cases meet contractual, regulatory and business goals as set down by the Manager of QI Programs.

Essential Functions

Quality of Care (QOC) Review

* Oversee all aspects of the QOC review process ensuring all contractual and regulatory timelines are successfully met.
* Provide technical expertise and training to all health plan staff on the identification of QOC issues.
* Lead the investigation process for all possible QOC issues, including but not limited to,conducting the medical record review, presenting the case to clinical and non-clinical health plan leadership, proposing next steps on the QOC investigation, completing all internal documentation completely and accurately, and ensuring all timelines are met.
* Act as the liaison between key departments that support the QOC review and process including but not limited to utilization management, case management, customer service, information technology, medical leadership, and outside agencies, all under the direction and management of the Manager of QI Programs.
* Create and present an overview of the QOC reviews in larger inter-disciplinary meetings
* Work collaboratively with IT to ensure all the proper coding and reporting of incidents are built into the various claims payment and authorization systems
* Lead the development and execution of any training guides or materials that can be used by health plan staff or the provider network to ensure compliance with the QOC review process.
* Ensure all communications to members and providers are professional, accurate, timely and meet all contractual and regulatory obligations,

Quality Improvement Project Management

* Under the direction of the Manager of QI Programs, lead the creation and execution of the Quality Management Program Description, the Quality Management Workplan and the Quality Management Evaluation
* Provide oversight and direction on the execution of the Quality Management Workplan, ensuring all quarterly updates are complete, accurate and timely. Identify barriers to the workplan as well as solutions on an ongoing basis and ensure the Manager of QI Programs is kept abreast of all issues.
* Lead and assist QI workgroups across a variety of clinical and non-clinical areas including health promotion and disease management, member satisfaction, and behavioral health. Identify opportunities to leverage new and existing resources both in house and externally with the goal of improvement outcomes and performance.
* Participate in any external audits by state auditors or accrediting agencies, providing support and leadership where needed as directed by the Manager of QI Programs or his/her supervisors.
* Prepare workflows, performance improvement project (PIP) reports and other documentation to meet internal and external regulatory requirements
* Prepare routine and ad-hoc performance and activity reports using trended data.
* Provide technical assistance to provider practice sites in achieving clinical and service quality improvement goals.
* Effectively present and represent AllWays Health Partners' interests externally to providers and other stakeholders.
* Effective present and respond to inquiries from employees, senior management and regulatory agencies.
* Other duties as assigned with or without accommodation.

Working Conditions and Physical Effort

* Work is normally performed in a typical office work environment.
* Occasional meetings outside the office are required.


* Bachelor's Degree plus 5-7 years of health plan related experience.
* RN degree License
* Minimum of 5 years leading quality improvement teams/efforts in either a provider practice or health plan.


* Master's Degree in Public Health preferred
* Medicaid/Medicare quality management experience preferred
* Project Management certification preferred.
* Minimum of 5 years working in Patient Safety or Risk Management, preferably within a health plan
* Demonstrate AllWays Health Partners' core brand principles of always listening, challenging conventions, and providing value.
* Bring fresh ideas forward by listening to and working with employees and the people we serve.
* Strong aptitude for technology-based solutions.
* Ability to inject energy, when and where it's needed.
* Respect the talent and unique contribution of every individual, and treat all people in a fair and equitable manner.
* Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
* Be accountable for delivering high-quality work. Act with a clear sense of ownership.
* Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
* Excellent critical thinking, analytical and organizational skills
* Proficient in Microsoft Office products
* Proficient in Visio or other flowcharting application
* Proficient in internet research
* Ability to work well both independently and in a team.
* Excellent oral and written communication skills
* Meticulous attention to detail
* Business writing and presentation skills; ability to write clear, concise reports, proposals and business correspondence
* Ability to influence others and persevere in situations
* Ability to initiate administrative activities as necessary and institute quality control procedures.
* Ability to manage multiple projects, meet deadlines and adjust to changes in company policies, procedures and priorities.
* Ability to read, analyze and interpret clinical research, general business periodicals, professional journals, government regulations and legal documents.
* Ability to effectively present and represent AllWays Health Partners' interests externally to providers and other stakeholders
* Ability to effectively present information and respond to inquiries from employees, senior management and regulatory agencies
* Pre-employment background check
* CORI background check, if applicable

Associated topics: americorps, chaplain, community support, customer experience, liasion, minister, pastor, program, project, staff

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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