What are the responsibilities and job description for the Clinical Quality Improvement Specialist position at Coordinated Care Services Inc?
Join us at Coordinated Care as a Clinical Quality Improvement Specialist , and contribute to our mission of delivering high-quality healthcare services to our members. In this role, you will work closely with our Medical Management / Health Services team to develop and implement effective strategies to improve healthcare outcomes and reduce costs.
About the Role : As a Clinical Quality Improvement Specialist, you will be responsible for identifying and addressing areas for quality improvement in our medical management programs. Your primary focus will be on developing and implementing evidence-based practices to improve healthcare outcomes and reduce costs.
Main Responsibilities :
Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice and improving the quality and cost of care.
Conducts regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Supports effective implementation of performance improvement initiatives for capitated providers.
Reviews claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.
About You : We are looking for a skilled professional with experience in clinical quality improvement and knowledge of quality accreditation standards. A Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Associations Department of Certifying Board Services is required. Current licensure as a MD or DO without restrictions, limitations, or sanctions from government programs is also necessary.
