Why Choose Jefferson Health Plans?
We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.
While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.
Perks of JHP and why you will love it here:
- Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
- Flextime and Work-at-Home Options
- Benefits & Wellness Program including generous Time Off
- Impact on the communities we service
We are seeking a talented and enthusiastic Clinical Programs Quality Coordinator to join our team!
Ensures Clinical Programs area is in full compliance with regulatory agencies and applicable accreditation requirements.
As the Clinical Programs Quality Coordinator, your daily duties may include:
- Conducts quality file reviews of clinical areas documentation to ensure compliance with department policies, procedures and standard operating procedures.
- Interprets care management clinical assessments and notes for relevancy, appropriateness of findings and clinically sound judgment as it relates to staff developing member care plans and follow up.
- Utilizes phone recordings to augment documentation findings.
- Work closely with the management team in the development of standards of performance, measurement against objectives, and collection of data for performance reporting that ensures compliance with contract requirements.
- Identifies quality/performance related issues, recommends possible solutions, and collaborates with the management team to implement an oversight/improvement program to ensure deficiencies are addressed and processes are put in place to ensure future compliance.
- Ensure care management approach is aligned with clinical guidelines and established procedures.
- Makes recommendations for further staff development and education based on findings and collaborates with the management team and medical directors to develop educational approaches to improve care.
- Provides analysis, tracking, and trending reports to the management team identifying deficiencies found during reviews for the purpose of improving quality. Regularly provides written findings of quality audit to the Director and appropriate Managers. Produces a brief audit report to leadership the summaries trends and actionable recommendations for improvement and/or sites best practices.
- Assist with targeted training on policies, procedures, and standard operating procedures as a result of quality reviews.
- Ensure full compliance with regulatory documentation that is appropriate for the department.
- Collaborate with Clinical Programs Director for annual regulatory workplan goals/objectives.
o Update workplan quarterly and review with Director prior to submission
o Draft annual program evaluation and review with the Director prior to submission.
- Gather all NCQA accreditation deliverables and review with the Director prior to submission to Accreditation Team
o Collaborates and follows the guidance of Accreditation team to ensure that documentation is presented in the manner that supports Accreditation process.
- Ensure timely submission of all documentation.
- Other duties as assigned.
Qualifications
- Current Pennsylvania state license to practice as a Registered Nurse (RN) or Social Worker required.
- Bachelor’s degree required.
- 5-7 years case management experience and certification as case manager preferred.
- Two years of managed care with knowledge of case management, NCQA Accreditation, in a managed healthcare environment required.
Skills, We Value:
- Capable of individual initiative, self-starter required.
- Excellent writing and communication skills required.
- Excellent organizational performance and achievement of goals
- Computer skill necessary with emphasis on Microsoft Office and Database applications
- Excellent organizational, analytical, interpersonal, time management and communications skills
- Strong leadership skills
- Strong conflict resolution and independent decision-making skills
- Expert process and project management ability
- Strong influencing, negotiation and analytical skills