Clinical Quality Performance Specialist

IntelliResume; North Carolina; Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Remote options

Hybrid work schedules

Health insurance

Paid time off

401(k) Tuition reimbursement

Job summary

AmeriHealth Caritas North Carolina is seeking a Clinical Quality Performance Specialist in Raleigh, NC. You will lead the clinical quality review of member concerns and medical records, perform care reviews, and ensure timely collection of records for evaluation.

The role emphasizes quality improvement practice with RN input, QAPI coordination, and annual policy adherence in a full-time, hybrid work arrangement.

Qualifications

• Minimum 3 years in clinical or service quality improvement or healthcare delivery.
• Strong maternal and/or women’s health clinical practice experience desired.

Responsibilities

• Lead and coordinate the clinical quality review of member concerns and medical records.
• Perform quality of care reviews for sentinel events and member concerns.
• Assure collection and organization of minimally necessary medical records.
• Summarize clinical findings for review by clinical committees.
• Assist with QAPI meeting packets and schedules.
• Review and approve the quality management work plan annually.
• Develop quarterly trending reports for QAPI and follow up on recommendations.
• Adhere to quality management policies including annual reviews and updates.
• Support annual medical record review activities including HEDIS and NCQA.

Skills

Clinical quality improvement

Healthcare delivery

Education

Associate's Degree in Nursing

Bachelor's Degree preferred

Job description

About This Role

The Clinical Quality Performance Specialist is responsible for leading and coordinating the clinical quality review process of member concerns and medical records at AmeriHealth Caritas North Carolina. This role is ideal for individuals with a strong background in clinical quality improvement and healthcare delivery.

Highlights

• Location: Raleigh, NC
• Schedule: Full-time, Monday through Friday, 8:30am EST to 5:00pm EST

What You’ll Do

• Lead and coordinate the clinical quality review process of member concerns and medical records.
• Perform quality of care reviews for all sentinel events and member concerns.
• Assure collection and organization of minimally necessary medical records for clinical review.
• Summarize clinical findings for review by clinical committees.
• Assist with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets and schedules.
• Review and approve the quality management work plan annually.
• Suggest new or improved quality management activities using Plan-Do-Study-Act Cycles.
• Develop quarterly trending reports for QAPI and follow up on recommendations.
• Adhere to quality management policies including annual reviews and updates.
• Support annual medical record review activities including HEDIS and NCQA.

Requirements

Education:

• Associate’s Degree in Nursing required; Bachelor’s Degree preferred

Experience:

• Minimum of 3 years in clinical or service quality improvement, healthcare delivery, or a related field
• Strong maternal and/or women’s health clinical practice experience desired

Licenses & Certifications:

• An active and unencumbered Registered Nurse license required

Benefits

• Flexible work solutions including remote options and hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k) Tuition reimbursement and more

About AmeriHealth Caritas

AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience in delivering comprehensive, outcomes-driven care to those who need it most. They offer integrated managed care products, pharmaceutical benefit management, specialty pharmacy services, and behavioral health services. Discover more about them at www.amerihealthcaritas.com.