Clinical Quality Review Specialist (Peer Review) - Pleasanton (QSOS V)

Job Summary: In addition to the responsibilities listed above, this position is also responsible for partnering with the Board of Directors in providing oversight of systems designed to monitor and ensure the quality care and services are provided at a comparable level to all members and patients across the continuum of care; serving as a point of escalation for complex issues in quality improvement systems; proactively identifying and communicating issues related to the organization meeting the standards established by regulatory agencies and accreditation organizations and meeting public expectations; ensuring the integrity of systems related to the selection, credentialing and competence of physicians and other health care practitioners; monitoring systems for granting or terminating clinical privileges, professional staff or medical staff or clinical staff membership, proctoring and continuing education; reviewing and approving medical staff or provider staff Bylaws, Rules and Regulations and amendments; and managing the oversight of systems of all contracted entities including but not limited to the Permanente Medical Groups. This role is also responsible for leading the peer review process, committees, and forums through evaluating and integrating direct information on hospital or health system performance; developing comprehensive feedback; and refining and communicating a strategic development plan to address needs and solve problems. Essential Responsibilities: Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams. Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others. Serves as the subject matter expert for clinical quality improvement processes and regulations practitioners, Quality Specialists, department managers, and peers, projects/committees, and internal stakeholders by: providing consultation on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a technical advisor on committees, projects to drive discussions on drawing guidelines on the enforcement, development of policies or procedures of regulations and auditing processes; maintaining collaborative, results oriented partnerships with practitioners and/or staff across clinical and administrative roles to ensure compliance with regulations and improve patient safety, reporting accuracy, and health outcomes and provides insight to the regulation climate; developing educational programs to raise awareness for current and changes in regulation requirement, internal concerns, and system/database usage; and anticipating issues, weighing practical and technical considerations in addressing issues, and coordinating with the appropriate stakeholders to develop resolutions. Develops the quality of care complaints and the review process by: coordinating grievance meetings, cases, reviews, referrals, or other mechanisms by collaborating with the ombudsman and external regulatory services; responding to and directing the preparations of all documentation, records, and information requested for specific patient case reviews; ensuring consistent follow through on quality of care concerns and analyzing and managing the process flow of investigations and claims for potential errors, red flags, and areas of improvement; and monitoring critical quality improvement metrics, cases, quality care incidents, and near misses according to established protocols on an ongoing basis. Develops risk management efforts by: researching corrective action plan for areas of improvement identified through utilization review, clinical records audit, claim denials, patient satisfaction surveys, and auditing surveys; serving as a subject matter expert for internal and external policies, regulations, scientific research, and legislation related to quality improvement; conducting complex root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches in order to identify areas of improvement and evaluate newly internalized processes and programs; and exercising independent judgment to elevate high-risk issues and trends to appropriate entity for resolutions. Provides consultation for the development of new clinical quality improvement programs by: consulting with teams and departments to develop guidelines, metrics, and operational definitions of quality improvement through qualitative and quantitative program evaluation, analyzing program performance, and peer/department review groups by challenging groups to provide creative solutions; leveraging a variety of health concepts, regulatory requirements, and change management principles to develop programs which optimize clinical quality, safety, or health outcomes; and researching and investigating innovative opportunities to develop KPs capacity as a learning organization, increasing capacity in areas such as video ethnography, patient-reported outcomes, and harvesting of best practices. Develops and implements systems, procedures, and forms to improve data management programs and utilizes data to monitor and improve performance of all worker and patient safety programs by: ensuring the quality improvement monitoring agenda for assigned departments includes all aspects of data management and analysis of trends and patterns of practice; conducting descriptive inferential, reliability, and confidence intervals statistical analysis for routine and special projects related to quality improvement evaluations; developing the procedures for gathering and entering data from databases, vital statistics, hospital patient discharge data, claims, and other relevant health sources; and analyzing and presenting reports (e.g., infection control research, utilization reviews, population health needs analysis, patient satisfaction) into specified formats for internal stakeholders and working with departments to develop action plans. Develops the process for regulatory audits and survey efforts by: serving as a liaison between external evaluators, vendors, and departments for onsite visits and evaluations; delivering ad hoc and complex requested audit documentation, information, reports, and tools throughout the auditing process; assessing the workflow of completing auditing surveys to identify gaps in completion and reporting; and conducting routine mock audits and surveys within departments to ensure auditing and survey preparedness. Seeks and addresses feedback from the evaluation of the cost effectiveness, practicality, and appropriateness of medical care given to patients by: creating the reports to be used in complex case reviews with senior leaders and practitioners; analyzing current standard operating procedures for treatment for specific medical codes to ensure equal and timely access to care and escalates concerns or improvements to senior leaders; analyzing current patient treatment plans to ensure patient needs are met in a timely manner and escalates issues to senior leaders; leading discussions with practitioners, staff, and patients to identify population health needs, such as community health concerns, access to transportation, knowledge of rights, reducing no shows, and others, and providing recommendations to senior leaders; and analyzing previous patient cases to identify areas of improvement for length of stay, type of treatment, and time of treatment and reporting recommendations to the Manager. #J-18808-Ljbffr NALHE