Overview

　　SCOPE OF WORK

　　The “QMPE Clinical Quality Reviews” position will be filled by a health professional with experience in clinical quality reviews/audits and health plan program administration to serve as a clinical auditor/reviewer in the Quality Management & Program Evaluation unit in support of the Medical Benefits and Certifications Unit. The “QMPE Clinical Quality Reviews” position will participate in all aspects of managing and evaluating the diagnostic and treatment benefit of a federal health plan reviewing clinical and administrative quality criteria against Program health care benefits to responders and survivors of the 9/11 attacks. Recommendations and outcomes of reviews will be made based on policy, program statute, collaboration with experts, clinical research and the “QMPE Clinical Quality Reviews” position’s medical and professional judgment. Additional duties include managing complex program deliverables, analyzing and manipulating clinical data, and collaborating with occupational health subject matter experts. The “QMPE Clinical Quality Reviews” position will interface with clinicians, medical administrators, and a diverse set of federal and contract staff. The work requires excellent organizational, verbal and written communication skills, attention to detail, innovative problem solving, and self-initiation. Guidance will be provided by the WTC Health Program leadership and management team, commensurate with level of duties.

　　The contractor is to maintain a healthy organizational culture in providing consistent and professional communication and services to WTC Health Program clients including health care beneficiaries and health care providers, the contractor shall participate in the occasionally held lunch/learn and other training sessions regarding WTC Health Program organizational culture.

　　Duties:

　　Serves as an expert to the Program on clinical quality reviews/audits; supports clinical reviews/audits based on official criteria and Program practices

　　Interprets clinical and administrative records against quality criteria, as defined by the Program and industry best-practices, and translates findings into communicable results

　　Reviews prior authorizations and other Program administrative documentation for completeness and alignment with Program requirements, makes recommendations to Program for approval/denial using clinical and professional judgement

　　Collects and analyzes clinical and administrative data; develops and completes reports and analyses for Program quality assurance and evaluation

　　Monitors government and industry for federal payor clinical standards and review criteria as well as industry standards (e.g., utilization management timeframes, evidence-based guidelines, etc.); makes recommendations to the Program

　　Makes recommendations for and edits and develops standard operating procedures, policies, and practices

　　Makes clear and succinct recommendations and provides appropriate feedback for corrective action, quality and process improvement, and educational opportunities

　　Identifies and refer cases for higher review to subject matter experts

　　Works independently, multi-task, problem solve and make informed and accurate recommendations to medical professionals based on current information. Provides analytic support of cost and utilization reporting

　　Understands complex legislative, regulatory, and/or policy guidance for use in executing daily activities

　　Monitors, coordinates, track multi-functional program deliverables, ensuring deadlines are met

　　The work entails both clinical and administrative aspects of health care delivery within a federal managed care system and involves collaboration with both clinicians and medical administrators. The WTC Health Program Quality Management and Program Evaluation Unit Chief, with support from the Medical Benefits and Certifications Unit Chief, will provide support and guidance to the contractor in the performance of these deliverables.

　　Organizational Context: This work is for the WTC Health Program only and work will be related to the support of this specific program-area medical management process of maintaining the health plan codebook and participating in prior authorization review and research. The work will likely include collaboration with other WTC Health Program personnel that work on the team.

　　Special Considerations or Requirements : The knowledge, skills and abilities are specific in this task area and shall include:

　　Bachelor’s or master’s degree in nursing from an accredited program (NLNAC or CCNE); current unrestricted Registered Nurse (RN) license from a U.S. State, District of Columbia, Commonwealth, or TerritoryOr

　　Graduation from a physician assistant educational program, accredited by the Accreditation Review Committee on Education for the Physician Assistant (ARC-PA) or its predecessors, at a college, university, or educational institution that is accredited by an accrediting body or organization recognized by the Secretary, U.S. Department of EducationAnd

　　5+ Experience working in clinical quality and/or experience working in a health plan or managed care setting; clinical quality/audit experience desirable

　　Proficient in Microsoft Office Suites, including Excel, Outlook, SharePoint

　　Company Benefits

　　PSI offers full-time, benefits eligible employees a competitive total compensation package that includes paid leave, and options for employer sponsored group medical, dental, vision, short-term and long-term disability, life insurance, AD&D coverage, legal services, identity theft, and accident insurance. Flexible spending account and health saving account options offer pre-tax savings for qualified medical, dental, and vision expenses. The company sponsored 401(k) retirement plan has an employer contribution match that is immediately vested. We invest in the professional growth of our employees through professional courses, certifications, and tuition reimbursement programs.

　　EEO Commitment

　　It is company policy to promote equal employment opportunities. All personnel decisions, including, but not limited to, recruiting, hiring, training, promotion, compensation, benefits, and termination, are made without regard to race, color, religion, age, sex, sexual orientation, pregnancy, gender identity, genetic information, national origin, citizenship status, veteran status, protected veteran status, disability, or any other characteristic protected by applicable federal, state, or local law.

　　Reasonable accommodations for applicants and employees with disabilities will be provided. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact Human Resources by emailing [email protected] , or by dialing 703-575-8400.

　　Location US

　　Posted Date 2 days ago (1/24/2024 9:51 PM)

　　Job ID 2024-10455