Conifer Health Solutions is a healthcare services company partnering with more than 800 clients to strengthen their financial and clinical performance. With over 30 years of healthcare industry experience in more than 135 local regions, Conifer helps clients transition from volume to value-based care, enhance the patient experience, improve quality and access to healthcare while controlling costs. In all, Conifer manages more than 24 million unique patient interactions, $30 billion in net patient revenue and $21.5 billion in medically managed spend. Conifer also provides technology and health management services to support care management for 5.7 million lives across the US.

JOB SUMMARY

The Clinical Quality Management Analyst, under the direction of the Director of Medical Management Quality, supports the initiatives that maintain and/or improve the quality of CCCS medical management services. Clinical Quality Management Analyst responsibilities include but are not limited to:

• Lead role in the processes necessary for compliance with federal and state law and standards of CCCS accreditation bodies
• Coordinates with Compliance, Legal, Ethics, Population Health Directors to establish guidelines and performance improvement activities to promote operational excellence within the utilization management, quality management, and case management programs.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Performs regular quality review audits on all medical management nurses to ensure compliance with Conifer Policy and Procedures, federal and state regulations as well as URAC and industry standards.
• Participates in quality initiatives, such as Quality Improvement Projects, Complaints, Member Satisfaction Surveys, and Significant Events through collection, analysis and reporting of data.
• Supports all external audits including UM/CM delegation audits and URAC accreditation. Supports URAC Accreditation through annual mock audits, tri-annual reaccreditations, and ongoing training and education to promote a quality and compliant medical management program.
• Supports all staff and client relations through complex case consultation, participation in client projects, client reporting, monitoring of SLAs, system enhancements, and efficiency initiatives.
• Maintains CCCS Policy and Procedures through required review and approval process working in conjunction with Compliance, Legal, and other departments.
• Maintains State Utilization Review Agent licenses. Tracks federal and state regulations updating Policy and Procedures accordingly.
• Provides quarterly QM Audit statistics to Quality Management Committee and leadership.
• Acts as liaison with delegated entities and vendors including MRIoA, external appeal review IROs, MCG, Language Line, and Relias.
• Supports Coniferâ��s Training Department during new hire Orientation as well as ongoing education to staff members.
• Provides advice, facilitation and training on the development, implementation, and technical aspects of the organizationâ��s quality improvement efforts.
• Analyzes Population Health Management benchmarks against the organizationâ��s performance with the goal performance improvement, increased knowledge, and overall impact on populations served.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment activity. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Competency in Microsoft Word, Excel, Adobe, Power Point
• Analytical and criterial thinking skills
• Ability to problem solve independently
• Working knowledge of the healthcare system
• Excellent written communication skills with ability to write in a professional, business manner
• Ability to develop creative solutions to complex problems
• Understanding of CMSA Standards of Practice and Professional Code of Ethics
• Understanding of relevant legislation, such as HIPAA, MHPAEA, ADA, ACA
• Excellent verbal communication skills

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• Bachelorâ��s Degree or higher
• At least five (5) yearsâ�� experience in Population Health, Case Management, Disease Management, Utilization Management, and/or Quality Management
• Large knowledge of Conifer Core Outcomes Optimization functionality and reporting applications
• At least one (1) year experience in a leadership/senior role

REQUIRED CERTIFICATIONS/LICENSURE

Include minimum certification required to perform the job.

• Active, unrestricted nurse license in State of Residence
• Certification in Case Management, Healthcare Quality, or similar certification related to medical management

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to work in sitting position, use computer and answer telephone
• Ability to travel
• Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office Work Environment

TRAVEL

• Approximately 5% travel may be required

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.