Company :

　　Highmark Health

　　Job Description :

　　JOB SUMMARY

　　This job coordinates accreditation and regulatory requirement activities related to performance measurement and outcomes on behalf of the organization. Collaborates with appropriate departments enterprise-wide for all product lines for Quality activities. Serves as a corporate resource, subject matter expert for Quality activities in the areas of compliance and process improvement for all product lines and as representative and collaborator with outside organizations on various performance measurement and outcomes topics/projects. Responsible for managing large projects associated with auditing network provider performance and identification of improvement opportunities through outcome analysis. May perform special studies or audits, clinical guideline development, network provider performance measurement and monitoring, and/or activities to educate or influence the behavior of members or providers. Communicates effectively with customers and colleagues by successfully identifying issues, conducting problem solving resolution and decision making sessions for problems and implementing solutions.

　　ESSENTIAL RESPONSIBILITIES

　　Develop, oversee and manage large projects targeting members and/or network providers to improve clinical care provided to health plan members, including data analysis; visualizing and resolving complex issues and developing and implementing interventions. Perform review of medical record documentation, practice guideline development and monitoring, network provider performance measurement and monitoring, activities to educate or influence the behavior of members and/or providers, etc.Perform web base reviews of research, best practices, professional guidelines, health education and any additional resources for clinical analysis purpose.

　　Coordinate and monitor the specific quality improvement programs to maintain regulatory compliance and quality accreditation for the corporation.

　　Fulfill the role of subject matter expert for the corporation regarding activities related to applicable quality standards and assigned accountabilities. Organize and provide consultative support to relevant corporate stakeholders. Facilitate work-groups on various activities to ensure compliance and implementation of services.

　　Promote a culture of performance excellence by enhancing job skills through quality process improvement and tools training / certification; participating in process and operational initiatives and building and maintaining effective relationships throughout the organization to advance Performance Excellence.

　　Other duties as assigned or requested.

　　EDUCATION

　　Required

　　Bachelor's Degree in NursingSubstitutions

　　Licensed Registered Nurse with 6 years experiencePreferred

　　NoneEXPERIENCE

　　Required

　　3 - 5 years in Nursing

　　1 - 3 years in Quality Improvement

　　1 - 3 years in Research and Development

　　Preferred

　　1 - 3 years in Cross-Functional Project Teams

　　1 - 3 years in Process Improvement

　　1 - 3 years in Regulatory Compliance

　　LICENCES AND CERTIFICATIONS

　　Required

　　Registered NursePreferred

　　NoneSKILLS

　　Collaboration

　　Continuous Improvement

　　Critical Thinking

　　Written & Oral Presentation Skills

　　Time Management

　　Clinical Research

　　Analytical Skills

　　Performance Improvement

　　Quality Management

　　Regulatory Compliance

　　Language (other than English)

　　None

　　Travel Required

　　0% - 25%

　　PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

　　Position Type

　　Office-Based

　　Teaches / trains others regularly

　　Rarely

　　Travel regularly from the office to various work sites or from site-to-site

　　Rarely

　　Works primarily out-of-the office selling products/services (sales employees)

　　Never

　　Physical work site required

　　Yes

　　Lifting: up to 10 pounds

　　Rarely

　　Lifting: 10 to 25 pounds

　　Does Not Apply

　　Lifting: 25 to 50 pounds

　　Does Not Apply

　　Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

　　Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

　　As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

　　Pay Range Minimum:

　　$57,700.00

　　Pay Range Maximum:

　　$106,700.00

　　Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

　　Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

　　EEO is The Law

　　Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

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　　For accommodation requests, please contact HR Services Online at [email protected]

　　California Consumer Privacy Act Employees, Contractors, and Applicants Notice

　　Req ID: J236280