CareFirst Careers

Quality Improvement Specialist

Resp & Qualifications

Company Description:
CareFirst BlueCross BlueShield (CareFirst), is the Mid-Atlantic region’s largest health plan, covering the healthcare needs of 3.4 million members. With the implementation of its Patient Centered Medical Home (PCMH) Program, CareFirst is a national leader in clinical innovation and quality programs. The company’s Total Care and Cost Improvement (TCCI) Programs support members along the care continuum, as they progress through various stages of health and illness. The program’s core is to provide incentives, health data, infrastructure, and resources that promote high quality, cost effective health care for members. This model has proven success since inception in 2011; there have been 19% fewer hospital admissions, 15% fewer days spent in hospitals, 20% fewer hospital readmissions for all causes, and reduced medical costs for patients covered by the PCMH program.

Job Description:
The Quality Specialist is part of a team responsible for helping to ensure that our 3.4 million members receive the highest quality care and service possible. This individual, in collaboration with others across the organization, is responsible for quality measurement collection and will use data to identify opportunities and work throughout the organization to implement quality improvement interventions.

This individual champions quality improvement across the company .Through relationships will key leads throughout the organization, they carry out the QI Program goals and objectives leading to compliance with regulatory and accreditation requirements and progressively increasing health plan performance.

This individual is a part of  a team of quality professionals to achieve the triple aim: improving health outcomes, reducing cost of care and improving the overall experience for members; as well as, physician satisfaction  through the following:
1) Carries out the region-wide quality improvement (QI) program;
2) Collects, analyzes and reports on mandated quality assessments;
3) Leads Quality Improvement teams; and
4) Monitors and collaborates with delegated/contracted partners to assure alignment with plan and regulatory standards.

ACCOUNTABILITIES:
Under the direct supervision of the Manager, Clinical Innovations, this associate’s accountabilities include, but are not limited to, the following:

1. Carries out the corporate QI program
The Quality Specialist, utilizes healthcare knowledge, business acumen and data fluency to drive quality improvement throughout the organization.

  • Supports the QI  infrastructure necessary to improve the quality and safety of clinical care and services;
  • Collaborates with functional leads throughout the organization   to assure compliance with regulatory and accreditation requirements;
  • Uses performance data from quality measurement and QI activities to improve the quality and safety of clinical care and services provided to CareFirst members;
  • Analyzes and evaluates the  effectiveness of quality measurement and activities  to identify and  prioritize process improvements and gaps in care ; and
  • Utilizes results from population based quality and satisfaction measurement to inform quality improvement interventions for the organization.


2. Collects, analyzes and reports on mandated quality assessment
Through effective relationships throughout the organization, with trusted partners, clinical practices providing care and with external regulators, the CareFirst Quality Specialist assures compliance and drives improvement. 

  • Maintains  knowledge of current accreditation, regulatory and healthcare quality, clinical practices, and quality measurement requirements and standards;
  • Monitors compliance to accreditation and regulatory requirements and engages functional leaders to support quality efforts;
  • Collaborates with functional leads to collect and analyze quality assessments for all aspects of plan operations, clinical care, network adequacy, experience of care and safety;
  • Oversees  performance of Delegated functions/ Vendor activities;
  • Analyzes processes, audit results and data trends to identify and prioritize opportunities;
  • Utilizes lessons learned and industry best practices to drive improvement; and
  • Coordinates, facilitates, document s and reports on all aspects of assigned project(s).


3. Leads quality improvement teams

  • Coordinates and leads QI related committees and/or work teams;
  • Conducts both quantitative and qualitative analysis to identify priorities;
  • Analyzes processes, results and trends to recommend actions and assist with implementation of strategies that drive continual improvement;
  • Documents and reports all aspects of assigned project(s) using project plans and work plans for tracking; and
  • Creates executive level and front line reports and presentations.

4. Monitors and collaborates with delegated/contracted partners to assure alignment with plan and regulatory standards
This individual assures that our delegated partners are providing services aligned with our PCMH/TCCI Programs and fully compliant with regulatory and CareFirst standards.

  • Leads an interdisciplinary oversight committee charged with monitoring delegated activities throughout the organization;
  • Oversees ongoing assessments of delegated activities to assure compliance with regulatory and accreditation requirements; and
  • Collaborates with trusted partners to close gaps in care, improve access, and improve health and operational outcomes.



QUALIFICATIONS:

Education/Experience:

  • Any of the following: Bachelor’s Degree or other advanced degree in healthcare related field or equivalent experience.
  • 2+ years of professional experience in business environment (healthcare, public health, health insurance, quality/process improvement or data management);
  • Training or certification in Quality or Process Improvement Methods, preferred – or related training in an analytic field, including engineering, public health, or data science;
  • Proven capacity to perform qualitative and quantitative data analyses and create innovative strategies and work with colleagues to address findings; and
  • Ability to learn the technical aspects of collection and reporting of both administrative and clinical aspects of quality measures.


Abilities/ Skills:

  • Excellent verbal and written communications;
  • Must be a critical thinker who uses sound judgment in the evaluation of performance throughout the organization;
  • Must possess data fluency and be skilled in analyzing and presenting data;
  • Broad knowledge of the healthcare industry including both clinical and operational aspects of Health Insurance Plan and products (preferred but not required); and
  • Able to motivate people and influence change in a complex organization.

Department

Department: Accreditation & Medical Program

 

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 5/17/2018

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:


The physical demands described below are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Occasional driving is required.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

Learn more about Medical Management