Quality Improvement Specialist

Information Technology
in Cypress
, CA
Reference: 19-03486


  • Support the development and implementation of quality improvement interventions and audits and assist in resolving deficiencies impacting plan compliance to regulatory and accreditation standards
  • Interface with a diverse range of clinical and administrative professionals
  • Resolve complex issues
  • Perform data analytic and reporting activities

Key Duties and Responsibilities:

  • Monitor quality improvement initiatives including but not limited to development and implementation of preventive health and chronic disease outcome improvement interventions such as newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys
  • Monitor and investigate all quality of care and collaborate with medical directors to determine impacts and next steps for actions
  • Monitor provider quality complaints to identify trends and educational opportunities for improvement
  • Analyze, update, and modify procedures and processes to continually improve QI operations
  • Collect and summarize performance data and identify opportunities for improvement
  • Serve as knowledge expert for continuous quality improvement activities, QIPS, PIPs and QIAs
  • Monitor and analyze outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met
  • Participate in site visit preparation and execution by regulatory and accreditation agencies (state agencies, CMS, AAAHC, URAC, NCQA, EQRO)
  • Conduct internal auditing of compliance with regulatory and accreditation standards
  • Support the implementation of the quality reporting infrastructure
  • Pursue methods to ensure receipt of data required for trending and reporting of various QI work plan metrics, perform adequate data/barrier analysis, develop improvement recommendations, and deploy actions as approved
  • Assist in activities to prioritize clinical and service improvement initiatives
  • Participate in various QI committees and work groups convened to improve process and/or health outcomes, and contribute meaningful detail, based on functional knowledge
  • Complete follow-up as assigned
  • Manage and monitor assigned quality studies
  • Investigate and incorporate national best practice interventions to affect greater rate increases
  • Ensure that documentation produced and/or processed complies with state regulations and/or accrediting body requirements
  • Ensure assigned contract/regulatory report content is accurate and that submission adheres to deadline
  • Complete Licensed Health Care Risk Management certification program
  • Perform annual update on Plan Risk Management program description
  • Coordinate the regular and systematic review of all potential adverse incidents in accordance with state statute
  • Complete AHCA Code 15 Reports for confirmed adverse incidents
  • Submit an annual AHCA adverse incident summary report
  • Present summary reports of reported AHCA Code 15 adverse incidents through the quality committee structure and Board of Directors
  • Perform other duties as assigned


  • A High School diploma or GED with a current unrestricted RN license
  • A Bachelor’s degree in Healthcare, Nursing, Health Administration, Public Health or related health field

Work Experience: 

  • 2+ years of experience in quality improvement
  • 3+ years of experience in managed care
  • Experience in compliance and accreditation
  • Knowledge of federal and state regulations/requirements

Licenses and Certifications:

  • Licensed Registered Nurse (RN)


  • Demonstrated written communication skills
  • Demonstrated interpersonal/verbal communication skills
  • Ability to multi-task
  • Ability to work in a fast-paced environment with changing priorities
  • Ability to effectively present information and respond to questions from families, members, and providers
  • Ability to create, review and interpret treatment plans
  • Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Knowledge of healthcare delivery
  • Knowledge of community, state and federal laws and resources
  • Demonstrated time management and priority setting skills
  • Ability to implement process improvements

Technology Proficiency:

  • Microsoft Excel
  • Healthcare Management Systems (generic)
  • Microsoft Word
  • Microsoft Outlook

Level of Supervision Received:

  • Plan and arrange own work, refer only unusual cases to supervisors or others