Clinical Quality Improvement Specialist

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.Position Overview Empower. Unite. Care.MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.Under the direct supervision of the MLTC Clinical Quality Manager, the Clinical Quality Improvement Specialist is responsible to review the Uniform Assessment System-NY (UAS-NY) assessments performed by the Assessment Nurses and UAS-NY vendors, ensuring quality and accuracy on documentation and compliance withJob DescriptionReview clinical documentation in order to ensure that all components of the UAS assessment meets quality standards and accuracy following MetroPlusHealth policies and NYS regulationsCompare UAS and Tasking Tool to ensure correlationUpload the UAS to Lenavi and Develop Task Based tool for membersAssist Assessment Registered Nurses, as needed, to determine areas that require immediate remediation and assist in resolving inconsistenciesPrepare various reports and correspondences as well as provide summary reports to highlight key findings for implementation of performance improvement plansMaintain a tracking tool that will log unacceptableinconsistent errors observed during quality reviewsCommunicate inconsistencesidentified changes to Assessment Nurses and vendors Work with management team to identify areas of continuing education for Assessment Nurses and vendors including MetroPlusHealth policies & procedures for UAS and Tasking Tool assessmentsAssess current quality metrics and identify areas for quality improvement including identification of inter-rater reliability scales and examination of intra-rater reliability upon analysis of the UAS-NY dataProvide feedback to the management team regarding Assessment Nurse documentationPrepare technical guides on Assessment Nurse documentation expectations and improvementAssist with special projects as assigned to meet departmental goals and policiesOversee vendor dashboards for quality initiativesReport weekly to management on UAS reviewsOther duties as assignedMinimum QualificationsBachelor's Degree from an accredited institution in Nursing or related health care field required2 years of experience in medical records review, claims processing, or utilization and case management in a clinical practice or managed care organizationExperience analyzing various types of data and processes in a versatile manner including ability to present findings and make recommendationsExperience with a corporate email system (Microsoft Outlook) including using and sharing calendar rights, Microsoft Word, and electronic Patient Health Information (PHI) database usage (medical records database)Microsoft Excel skills with the ability to edit, search, sortfilter, formatuse styles, create tables, calculate data using functions and formulas and createuse PivotTables for analyzing dataProficiency with healthcare terminology such as ICD-10 codes and medical abbreviationsLicensure andor Certification RequiredActive, unrestricted NYS Registered Nurse (RN) licenseState registration with UAS for long-term care in NY State (training to be completed during employment)Professional CompetenciesIntegrity and TrustCustomer FocusFunctionalTechnical skillsWrittenOral Communication

Created: 2025-02-28