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Quality Operations Specialist (myNEXUS)

Location: San Antonio, TX
Company: Anthem, Inc
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SHIFT: Day Job
SCHEDULE: Full-time
Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, it's a powerful combination. It's the foundation upon which we're creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.
myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.
Job Summary:
The Quality Operations Specialist will support accreditation and general quality management initiatives, including but not limited to working closely with the Director of Quality and the Chief Clinical Officer to insure the company meets the standards for corporate compliance, and obtaining and maintaining applicable accreditations. The Quality Operations Specialist performs independent audits of authorizations in accordance with myNEXUS policies and procedures, clinical guidelines, applicable regulatory standards and client requirements. The Quality Operations Specialist also assists with monitoring, research, tracking and reporting of quality and compliance activities to support delegation reporting, privacy disclosure investigation, appeals processing, UR licenses, development and management of policies and procedures, quality improvement projects, and auditing programs and metrics. The incumbent will assist with training new employees on the company policies and procedures and reinforce said policies and procedures with employees on an ongoing basis.
- Independently use discretion and judgment to evaluate objective and subjective clinical documentation of member authorizations to assess performance of nursing skill and the skills of other allied health professionals, based on Business Unit expectations for performance
- Assists activities related to accreditation and delegation and sub-delegation oversight.
- Assists with development, maintenance and monitoring of quality improvement projects and other quality department initiatives as defined by the quality and UM workplans.
- Applies advanced knowledge to conduct multispecialty subjective assessments to evaluate the skills of nurses and other allied health professionals
- Consults with Medical Directors to calibrate on subjective assessments to ensure consistency of feedback related to complex, high risk cases
- Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow myNEXUS policies, State regulations and Accreditation standards
- Collate all data available to illustrate a full picture of an individual staff members performance (Work Force Management data, phone metrics, other)
- Generate reports /findings of reviews for the Clinical Management Teams: in a clear, concise manner that is understandable and actionable
- Provide consultation with Clinical Management leaders as requested to support staff coaching and development efforts
- Assist the Clinical Management team, as needed, to determine areas that require immediate remediation and assist myNEXUS employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and member engagement
- Identifies tracks and records best practices, sharing the specifics with team leadership
- Participate in training and performance improvement related projects to support staff development as well as assist with the training of new employees
- The Quality Operations Specialist will highlight key findings for implementation of performance improvement plans when necessary
- Assists with maintenance of policy and procedure tracking in the master tracking system. Monitors the annual review cycle of policies and submits to committees for review as needed.
- Assists with the development, implementation, reporting and tracking of IRR case studies.
- Assists with responding to, tracking, investigation and monitoring of incident reporting for appeals, grievances, privacy disclosures, patient safety and quality of care issues as required per specified timeframes.
- Participate in URAC and NCQA accreditation activities
- Work with colleagues across business units to ensure that process and procedural changes are reflected in staff member documentation such as job aids and policies
- Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings
- Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings
- Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served
- Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner
- Ability to work and interact with professionals as part of an interdisciplinary team
- Self-motivated, flexible person who can flourish in an office setting with colleagues as well as in a self-structured independent setting
- Ability to accept constructive feedback for continual improvement
- Ability to add to a team atmosphere where a team approach is highlighted and valued
- Thrives in a process based transactional work environment
- Able to work independently; self-motivated with good organizational skills
- Quickly adapt to new technology
- Must stay abreast of all customer specific details, to ensure high quality customer service
- Participates in on-call coverage schedules as required.
- Accept additional assignments willingly
Professional Responsibilities:
- Excellent organizational, interpersonal, written and verbal communication skills
- Maintains member confidentiality at all times
- Capable to apply and conduct a logical approach to audits to arrive at fact-based recommendations based on source of truth documentation
- Ability to remain a neutral party, negotiate, and drive to expected result
- Follows all company policies related to time records
- Has a passion for quality and performance improvement
- Adheres to dress code, appearance is neat and clean.
- Completes annual education requirements in a timely fashion.
- Maintains confidentiality of employee, company and/or patient information at all times.
- Reports to work on time and from breaks as scheduled, completes work within designated time.
- Follows all company policies related to time records and time off policies.
- Attends staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested.
- Represents the organization in a positive and professional manner.
- Actively participates in performance improvement and continuous quality improvement (CQI) activities.
- Complies with all organizational policies regarding compliance and ethical business practices.
- Communicates and demonstrates the mission, core values, ethics and goals of the Company, as well as the department.
Education and Experience:
Educational Requirements:
- Bachelor's degree in Nursing or Therapy and 7-10, years combined experience in direct patient care; and, utilization review, quality, audit, or clinical compliance experience; or,
- Clinician with 5+ years combined clinical experience; and utilization review, quality, audit, or clinical compliance experience.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For® , is ranked as one of the 2020 World's Most Admired Companies among health insurers by Fortune magazine, and a 2020 America's Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.
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