• Quality Review Analyst – Care Management

    Location US-IA-Des Moines
    Job ID
    Clinical/Provider Support
    Requires Non-Compete?
  • Job Summary

    About the Team: Wellmark’s Care Management Operations team supports a diverse department by providing training, technical writing, system administration, project support, and quality review.


    About the Role: No two days will be the same! You’ll complete quality review for work performed by clinical and non-clinical staff, including review of processes, adherence, phone calls, and clinical documentation. You’ll also provide quality review reports, results, and trends to the Team Leader and will assist with cross-training team members on procedures and guidelines for department functions. Additional accountabilities could include assisting with development and implementation of quality or process improvement initiatives, and completion of audits, research, and analyses to support performance metrics and reporting across the department.


    Ideal Candidates: Have at least four years of clinical/industry experience and an active and unrestricted RN license. They’re coaches at their core and view their role as a support system for team members across the department—the ability to help others learn, grow and succeed energizes them. They listen first, seek to understand, and approach their work with flexibility. They’re also effective at facilitating crucial conversations and providing constructive feedback to others.

    Minimum Qualifications Required (all must be met to be considered)

    • Completion of an accredited registered nursing program.
    • Active and unrestricted RN license in Iowa or South Dakota. Individual must be licensed in the state in which they reside.
    • 4+ years of clinical or equivalent industry experience including:
      • Coaching, reviewing, or evaluating others’ work.
      • Demonstrated knowledge of complex operational processes or care management-related quality reviews.
    • Strong written and verbal communication skills, including the ability to effectively coach others to improvements, facilitate crucial conversations, and give/take feedback in a constructive manner.
    • Strong interpersonal skills with the ability to foster cooperation and collaboration across teams.
    • Analytical skills with the ability to effectively evaluate data/trends, solve practical problems, and conduct audits and research as needed. Attentive to details and quality.
    • Effective planning, time management, prioritization and organization skills. Flexible and adaptable with changing priorities.
    • Experience with the Microsoft Office Suite, electronic charting, or documentation systems. Technical aptitude to learn new systems.
    • Process improvement focused.

    Hiring Specifications Preferred

    • Bachelor's Degree in Nursing or related field.
    • Prior quality review experience.

    Job Accountabilities

    a. Assess and evaluate the accuracy of standards to complex Care Management processes, phone calls and/or clinical and administrative documentation in accordance with business objectives and goals identify documentation issues and provide effective business answers and solutions.

    b. Perform audits, research and analysis to support metrics and reporting across the department. Ability to generate reports, and create documents that communicate results of analysis, research, and metrics to demonstrate trends, changes, and results of projects and activities. Use clinical knowledge to interpret results and make recommendations for process improvements and/or training needs. Participate in projects as needed to support the goals of the department.

    c. Provide timely and accurate information regarding procedural/documentation concerns, team needs, and error trends to the medical management leader. Provide team and individual contributor quality reports to leaders regarding quality results, error trends, and issues that must be addressed, including reporting on trainee results and progression towards regular quality reviews.

    d. Provide and/or assist with crosstraining team members on procedures and guidelines for Care Management functions.

    e. Generate and ensure accurate reporting of quality measurements through Verint for leadership and stakeholders by maintaining performance metrics for each team member and provide a rollup quality report for the Care Management teams. Proactively provide comprehensive analysis to identify potential quality issues and recommends applicable solutions.

    f. Serve as the business subject matter expert on department QA software Verint and collaborates with technical subject matter experts to coordinate changes, resolve issues, etc.

    g. Research issues identified in quality reviews by performing additional investigation into operational procedures, as well as communicating with the operating areas, if needed.

    h. Document and update quality review and procedural documents with edits and revisions as changes in guidelines or regulations occur. Proactively submit updates to Care Management processing documents.

    i. Actively participate in project and process improvement initiatives, including user acceptance testing when appropriate. Share and encourage ideas and collaborates with the team to create efficiencies in work processes and efforts.

    j. Comply with regulatory standards, accreditation standards and internal guidelines remain current and consistent with the standards pertinent to the Care Management Operations team.

    k. Develop and maintain positive team member relationships.

    l. Other duties as assigned.


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