Quality Initiatives Specialist Senior

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Role Overview:

The Quality Initiatives Specialist Senior is responsible for leading and supporting Quality Improvement (QI) initiatives that enhance healthcare service delivery, clinical activities, regulatory compliance, provider services, and member services. This role plays a key part in developing and implementing strategies that drive excellence in quality outcomes. The Quality Initiatives Specialist Senior collaborates with cross-functional teams to ensure continuous improvement and adherence to federal, state, NCQA and State specific measures/requirements.

Work Arrangement:

• Remote role.

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Quality and Performance Improvement Initiatives

• Lead the development, implementation, and monitoring of quality improvement projects to enhance healthcare service delivery and clinical outcomes.
• Identify trends and opportunities for improvement by analyzing key performance indicators (KPIs), healthcare utilization data, and member/provider feedback.
• Utilize quality and process improvement methodologies to drive efficiency and effectiveness in operations and develop solutions to improve Behavioral Health (BH) outcomes.
• Lead root cause analysis and corrective action plans to improve performance.
• Function as a key liaison between internal departments, external partners, and regulatory agencies to align quality initiatives with organizational goals.
• Foster a culture of continuous improvement and patient-centered care within the organization.;
• Provide guidance to QIS and QIC roles.
• Engage in strategic decision making.
• Lead workgroups with PerformCare departments and Primary Contractors/Overseeing key projects.

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Data Analysis & Reporting

• Collect and interpret performance data to assess progress toward quality improvement goals.
• Generate reports and presentations for senior leadership highlighting key insights and recommended actions.
• Utilize healthcare data systems (e.g., HEDIS, State Specific Measures, etc.) to drive decision making.

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Regulatory Compliance & Accreditation;

• Ensure compliance with all regulatory and accreditation requirements, including HEDIS, State specific measures/requirements, NCQA accreditation, applicable State, Federal and NCQA standards, and State Program Standards and Requirements.
• Develop policies, procedures, and best practices aligned with industry standards that support accreditation readiness.;
• Prepare reports and documentation outlining findings and recommendations.

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Provider and Member Services Enhancement

• Collaborate with provider relations teams to enhance provider engagement and performance.
• Collaborate with member services teams to identify and address barriers to member access, satisfaction, and care coordination.

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Education and Experience:

• Bachelor's Degree in Healthcare Administration, Public Health, Nursing, Business Administration, or a related field.
• Master's Degree: in Healthcare Administration, Public Health, Nursing, Business Administration, or a related field.
• Minimum of 5 years in quality improvement, performance improvement, or regulatory compliance in a healthcare or insurance setting.
• Strong communication skills with diverse audience including the ability to articulate to all levels of the organization, state contractors, and stakeholders.
• Knowledge of healthcare quality metrics and regulations.
• Familiarity with process improvement methodologies.

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Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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Our Comprehensive Benefits Package

Flexible work solutions including remote options, 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