Clinical Quality Performance Specialist

About This Role

The Clinical Quality Performance Specialist is responsible for leading and coordinating the clinical quality review process of member concerns and medical records at AmeriHealth Caritas North Carolina. This role is ideal for individuals with a strong background in clinical quality improvement and healthcare delivery.

Highlights

• Location: Raleigh, NC
• Schedule: Full-time, Monday through Friday, 8:30am EST to 5:00pm EST

What You’ll Do

• Lead and coordinate the clinical quality review process of member concerns and medical records.
• Perform quality of care reviews for all sentinel events and member concerns.
• Assure collection and organization of minimally necessary medical records for clinical review.
• Summarize clinical findings for review by clinical committees.
• Assist with Quality Assessment and Performance Improvement Committee (QAPI) meeting packets and schedules.
• Review and approve the quality management work plan annually.
• Suggest new or improved quality management activities using Plan-Do-Study-Act Cycles.
• Develop quarterly trending reports for QAPI and follow up on recommendations.
• Adhere to quality management policies including annual reviews and updates.
• Support annual medical record review activities including HEDIS and NCQA.

Requirements

Education:

• Associate’s Degree in Nursing required; Bachelor’s Degree preferred

Experience:

• Minimum of 3 years in clinical or service quality improvement, healthcare delivery, or a related field
• Strong maternal and/or women’s health clinical practice experience desired

Licenses & Certifications:

• An active and unencumbered Registered Nurse license required

Benefits

• Flexible work solutions including remote options and hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k) Tuition reimbursement and more

About AmeriHealth Caritas

AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience in delivering comprehensive, outcomes-driven care to those who need it most. They offer integrated managed care products, pharmaceutical benefit management, specialty pharmacy services, and behavioral health services. Discover more about them at