Market Clinical Quality Specialist II

🔥 17 hours ago

🇺🇸 United States – Remote

💵 $72.2k - $115.5k / year

⏰ Full Time

🟢 Junior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Complete assigned case/file reviews to ensure adherence to regulatory requirements and Standard Operating Procedures (SOPs) • Conduct monthly inter-rater reliability monitoring of case reviews • Identify training and development opportunities and collaborate with peers and Care Management to develop education and training • Assist Management with reporting case reviews at aggregate and individual contributor levels • Serve as a subject matter expert in assigned areas • Participate in interdepartmental meetings and workgroups regarding Care Management procedures • Provide cross-functional assistance for monitoring, accreditation and operational responsibilities • Maintain familiarity with applicable Federal and State Requirements, including Corporate Integrity Agreement responsibilities • Monitor regulatory changes, identify impacted areas, communicate changes and assist with implementation • Pursue best practices and improvement opportunities for health services monitoring and accreditation • Facilitate implementation of improvement initiatives • Perform other job-related instructions as requested

🎯 Requirements

• Associate of Science in Nursing (ASN) is required • One to three (1 to 3) years of experience in Quality Improvement, Project Management, Case Management or Utilization Review is required • Current, unrestricted Registered Nurse (RN) licensure in state of practice is required • Bachelor of Science in Nursing (BSN) is preferred • Minimum of three (3) years of diverse clinical experience as an RN is preferred • Intermediate proficiency 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 with 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 • Case Management Certification, such as Certified Case Manager (CCM), is highly preferred

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support