Quality Performance Specialist

Duties

• As part of the Quality Management team, the Quality Performance Specialist is responsible for the coordination and ongoing monitoring of QI program objectives, including the delivery of performance improvement projects for service and clinical activities, integrating the quality improvement plan into all departments and facilitating HEDIS, CAHPS and NCQA accreditation activities.
• Implements and supports the overall implementation of quality programs that meet or exceed applicable State, Federal and NCQA standards.

Principal Accountabilities

• Executes on organizational efforts in ongoing quality improvement processes to ensure compliance with State, Federal, regulatory and accrediting body s standard requirements.
• Responsible for completion and analysis of annual HEDIS results and works with all areas to integrate results into departmental goals.
• Responsible for the successful development and evaluation of an annual QI work plan and program description by facilitating QI throughout the organization.
• Identifies resolves and/or escalates problematic QI areas that may place plan at risk of not achieving annual goals.
• Collaborates with Provider Services and Member Services to complete analysis of annual satisfaction surveys and works with all areas to integrate results into departmental goals.
• Participates in the development, implementation and maintenance of QI policies and procedures.
• Serves as a resource to other departments in completing QI goals.
• Works professionally and efficiently with all functional areas in meeting organizational and departmental quality goals.
• Participates on QI committees structured to achieve outcomes success and completes committee documentation that is consistent in meeting regulatory and accrediting body requirements.
• Leads and monitors activities related to Critical Incident (CI) tracking, reporting, and resolution in alignment with OLTL and regulatory timelines, ensuring timely closure and documentation integrity.
• Reviews and evaluates CI submissions to ensure accuracy, compliance with internal protocols, and alignment with reporting standards.
• Partners with internal departments, Service Coordination (SC), and external vendors to investigate, resolve, and prevent recurrence of incidents impacting member safety and well-being.
• Ensures appropriate escalation of high-risk or sentinel events and collaborates on corrective action plans as needed.
• Tracks CI trends and develops recommendations for leadership to support process improvement, risk mitigation, and QAPI planning.

Skills

• Managed Healthcare experience preferred.
• Successful management of NCQA accreditation survey preferred.
• Excellent organizational, analytical and interpersonal skills.
• Excellent written and verbal communication skills.
• Ability to work successfully within all levels of the organization.
• Ability to design, develop and implement projects to address financial, quality and service improvements.
• Proficient PC skills in a windows based environment.

Education

• Associate s Degree or equivalent work experience required.
• Bachelor s Degree preferred
• Minimum of 3 years in clinical or service quality improvement required
• Minimum of 3 years in healthcare delivery required.