Senior Clinical Quality Analyst - Remote

Join WellMed

Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Explore rewarding opportunities for physicians, clinical staff and non-patient-facing roles. Join us and discover the meaning behind Caring. Connecting. Growing together.

Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs related to CMS Stars, HEDIS Measures and CAHPS/HOS. Conducts clinical quality data and reporting analysis with professional slide deck presentation of information. Responsible for the reporting and analysis of member care quality and for the development of plans, projects, and programs to support continuous quality improvement using HEDIS and other tools.

If you are able to work on Eastern Time, You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Assesses and interprets customer needs and requirements
• Identifies solutions to nonstandard requests and problems
• Solves moderately complex problems and/or conducts moderately complex analyses
• Summarizes actionable information in slide decks at appropriate level of communication
• Works with minimal guidance; seeks guidance on only the most complex tasks
• Translates concepts into practice
• Provides explanations and information to others on difficult issues
• Coaches, provides feedback, and guides others
• Acts as a resource for others with less experience
• Collect Quality data and/or information based on applicable standards, state/federal or other regulations, customer, or consumer requests, internal requests, or project assignments
• Identify appropriate sources for data or information either internally or externally and collect data/information Develop effective methods for data/information collection
• Identify appropriate data platform or application (e.g., data bases, Intranet source, Internet source, Microsoft Excel, Smartsheet) and utilize to collect data or information
• Investigate Quality problems identified and collect additional information to close gaps
• Work cross functionally and coordinate with others internally or externally to gather information; overcome challenges to obtaining needed information
• Evaluate data and/or information to identify inconsistencies, trends, other information needed, etc. (e.g., develop and/or run data queries, data comparisons across sources)
• Analyze and interpret data or information (e.g., clinical, administrative, Quality) to ensure they meet standards, are compliant and/or are accurate and complete
• Provide explanations or updates when data/information (e.g., clinical, administrative) are not accurate or unclear Explain the characteristics of the data/information (e.g., clinical, administrative) including any unique attributes
• Identify Quality improvement or intervention opportunities and work cross-functionally to develop interventions or recommendations presented in a summarized format
• Develop or update work plans (e.g., annual work plan)
• Develop or update program descriptions (e.g., annual program descriptions)
• Develop program evaluations (e.g., annual program evaluation)
• Develop, update, and/or review policies and procedures
• Review results, conduct analyses (e.g., evaluate against goals/effectiveness of interventions over time), and prepare reports on findings with summarized recommendations
• Follow regulations and internal or external protocols for communicating information or data
• Utilize computer systems to identify and annotate information
• Load completed information into relevant systems according to specifications
• Develop an understanding of the intended audience and determine the best method to communicate data or information
• Communicate Quality data or information in writing or verbally
• Report results (e.g., quality improvement initiatives) to committees, Board of Directors, external stakeholders, regulatory agencies, etc. and respond to questions or solicit feedback and input
• Develop understanding of customer requirements and/or expectations and anticipate needs to determine appropriate course of action
• Develop audit or review processes (e.g., automated/technically driven)
• Review relevant agreements (e.g., contractual, intersegment) and obtain clarification as necessary
• Read and interpret standards/requirements and/or technical specifications (e.g., structure and process, CMS star ratings,, URAC, NCQA/HEDIS/ CAHPS/member satisfaction specifications, SNP)
• Evaluate current processes, compare to relevant standards or specifications, and identify gaps in compliance or performance
• Perform/participate in assessments of the audit or review (e.g., interrater reliability of audit findings across auditors)
• Work cross functionally, making recommendations or clarifying information to assist in closing gaps that are identified or meeting customer expectations
• Work with auditors or key stakeholders for review/approval of results
• Develop and/or assist with corrective action plans based on audit findings or customer feedback
• Review processes and performance against customer expectations to provide needed information or service
• Define project scope and develop project plan
• Identify and recruit appropriate staff to assist with projects as necessary
• Coordinate with others to set appropriate deadlines when necessary
• Collaborate with stakeholders for review, input, and/or approval at key milestones
• Manage key relationships (e.g., vendors, stakeholders, regulatory bodies) to ensure milestones are achieved and performance objectives are met
• Manage or actively participate in meetings (e.g., schedule, present, document meeting results, facilitate)
• Provide information and feedback to project team with respect to achievement of objectives
• Leverage clinical expertise to inform decision making and program development
• Track timeframes/deadlines and collect data or information within required timeframes
• Identify, prioritize, and proactively communicate potential barriers or risks to key stakeholders
• Educate, motivate, and/or influence others (e.g., leadership, other stakeholders, including those for whom there is no direct line of authority) to understand the overall scope, overcome potential barriers, and engage in and commit to the process
• Communicate and explain applicable standards (e.g., industry/performance) and/or technical specifications and identified gaps and/or changes in applicable standards
• Develop educational materials (e.g., cross functional staff materials)
• Work with others to ensure messaging to cross functional staff is appropriate to the audience, complete/accurate, and compliant (e.g., with external/internal regulations and protocols)
• Train others on relevant policies, rules, or regulations (e.g., appropriate release of data, handling protected health information)
• Serve as a resource providing explanations and expertise (e.g., providing information to others, satisfaction survey, vendors)

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• 2+ years managed care experience
• Experience working with regulatory requirements and accreditation standards (HEDIS, NCQA, JCAHO)
• Experience in reporting, data analysis, and data management
• Knowledge of managed care requirements related to clinical quality
• Demonstrated ability to assist with focusing activities toward a strategic direction and achieve targets
• Advanced / Expert level of Excel and Power Point
• Ability to work standard business hours in EST zone
• Ability to travel up to 10%

Preferred Qualifications:

• Tableau or similar data base and reporting experience
• Experience creating reports related to quality improvement/performance outcomes
• Proven ability to deal with ambiguity and drive results
• Proven desire to make an impact, manage multiple tasks, and shift priorities quickly
• Proven solid interpersonal skills and the ability to influence others
• Proven solid communication skills, written and verbal
• Proven leadership skills and results oriented

*All employees working remotely will be