Job Summary:

Job Summary:

Enterprise Clinical Quality Specialist III is responsible for performing quality monitoring activities of clinical and non-clinical areas for compliance with National Committee for Quality Assurance (NCQA) and identified State and Federal requirements.

Essential Functions:

• Responsible for monitoring activities via Guiding Care, OnBase, Streamline, Facets, MHK, and CareSource policy and procedures
• Assist in identifying and evaluating the organizations risk areas related to accreditation, state and federal requirements and provide input to effectively communicate evaluation and recommendations to management
• Responsible for conducting independent random and scheduled monitoring activities for departments associated with NCQA. Additionally, responsible for monitoring of some state and federal requirements
• Analyze the quality assurance results and make recommendations for corrective action when problems are identified
• Provide feedback to all associated departments with quality monitoring variances and document corrective action and follow up
• Provide documentation for discussion at meetings and prepare minutes with follow-up action items
• Prepare statistical reports outlining departmental error rates/trends monthly for review
• Responsible for follow-up on designated case and file review findings
• Functions as a resource for business and clinical personnel in resolving questions related to documentation requirements and quality monitoring activities
• Responsible for ongoing educational programs and individual education within all departments that have quality monitoring requirements related to accreditation, state and federal requirements
• Assist in preparing cases/files for NCQA Onsite Survey file reviews
• Perform any other job duties as requested

Education and Experience:

• Completion of an accredited Registered Nurse (RN) degree program is required
• A minimum of three (3) years of clinical experience is required
• Minimum of three (3) years of managed care experience is preferred
• Experience in case management, managed care, or utilization review is preferred
• Experience in quality improvement and/or auditing is preferred
• Accreditation experience is preferred

Competencies, Knowledge and Skills:

• Microsoft office proficiency and/or Guiding Care proficiency
• Knowledge of NCQA
• Quality improvement process and analysis skills
• Strong people/interpersonal skills
• Strong organizational, problem solving and decision-making skills
• Ability to work on multiple projects
• Excellent oral and written communication skills
• Strong attention to detail

Licensure and Certification:

• Current, unrestricted Registered Nurse (RN) licensure is required in state of practice

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

• Create an Inclusive Environment

• 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 inclusive environment that welcomes and supports individuals of all backgrounds.