Job Summary:

The Market Clinical Quality Specialist II completes assigned case/file reviews to ensure adherence to regulatory requirements and identified Standard Operations Procedures (SOPs)..

Essential Functions:

• Ensure compliance with adherence to regulatory requirements and identified Standard Operating Procedures (SOPs) through monthly inter-rater reliability monitoring of case reviews
• Identify departmental training and development opportunities and work collaboratively with peers and Care Management to develop  the needed education and/or training
• Assist Management with reporting of case reviews that can be communicated at overall aggregate and individual contributor levels
• Subject matter expert (SME) in assigned area(s)
• Participate in interdepartmental meetings/workgroups, as directed, to ensure that new operational procedures and updates to existing procedures for Care Management (CM) are compliant with contract requirements
• Provide cross-functional assistance to meet monitoring, accreditation and operational responsibilities to ensure adherence to regulatory requirements
• Maintain familiarity with all applicable Federal and State Requirements, which include the Corporate Integrity Agreement responsibilities; also responsible for monitoring changes within those requirements, identifying the areas that will be impacted, communicating the changes and assisting with implementation of the changes
• Continuously pursue and identify best practices as well as opportunities for improvement and facilitate implementation of improvement initiatives for health services monitoring and accreditation
• Perform any other job related instructions as requested

Education and Experience:

• Associate of Science in Nursing (ASN) is required
• Bachelor of Science in Nursing (BSN) is preferred
• One to three (1 to 3) years of experience in Quality Improvement, Project Management, Case Management or Utilization Review is required
• Minimum of three (3) years of diverse clinical experience as an RN is preferred

Competencies, Knowledge and Skills:

• Intermediate in Microsoft Excel, Access and Word
• Intermediate skill level with SharePoint
• PowerPoint and Visio preferred
• Strong written and verbal communication skills  Ability to work independently and within a team environment
• Familiarity of the healthcare field
• Knowledge of Medicaid and Medicare
• Effective listening and critical thinking skills
• Strong interpersonal skills and high level of professionalism
• Effective problem solving skills with attention to detail
• Ability to develop, prioritize and accomplish goals
• Technical writing skills
• Ability to coordinate complex projects and multiple meetings
• Ability to work with a variety of disciplines and levels of staff across departments

Licensure and Certification:

• Current, unrestricted Registered Nurse (RN) licensure in state of practice, is required
• Case Management Certification, such as Certified Case Manager (CCM) through the Commission for Case Management Certification (CCMC), is highly preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.