Job Description

Where Compassion Meets Innovation And Technology

Thank you for your interest in joining our team! Please review the job information below.

General Purpose Of Job: The Process Improvement & Quality Assurance Program (PIQA) supports and educates Driscoll Health Plan (DHP) Population Health staff. The PIQA program is designed as an integral component of a proactive and progressive program to maintain compliance with Federal, State, Regulatory, and accrediting body standards. The PIQA Specialist uses tools to compare current work with evidence-based population health standards of practice, and Service Coordination strategies as staff complete Service Assessment Instruments (SAI), Individual Service Plans (ISP) and various mini-assessments used in promoting holistic care for DHP members. The program consists of chart and record reviews for early identification and intervention when irregularities are identified in documentation. Recorded telephonic interactions between Population Health staff, and stakeholders are also monitored for regulatory compliance. The goal of the program is to verify accuracy and proactively retrain staff who may need redirection. PIQA program also supports the Population Health Department by preparing and presenting training materials and courses as directed by contractual requirements as well as needs identified during quality audits. Team members are also tasked with monitoring complaints made by Members or Providers, ensuring complaints are documented properly and resolved timely. In addition, the PIQA RN will staff the DHP Nurse Advice Line (NAL). The purpose of the NAL is for Providers, Members, and Members Legally Authorized Representatives (LAR) to call for clinical information, guidance on specialty referrals, and requests for specialty Provider consultations.

Essential Duties And Responsibilities: The PIQA Specialist applies expertise in data analysis to give insight into operational PH measurement of contractually required documentation. The incumbent will engage with clinical teams composed of PH leadership, managers, and front-line staff to improve outcomes and PH Operations. This should be accomplished through daily review and analysis, collaborating with colleagues, actively participating to effectively improve documentation. Team members work collaboratively to create and present training modules and associated content as guided by contractual requirements and the outcomes of analysis completed on the results of chart and call audits. Additionally, the incumbent will apply knowledge and evidence-based nursing protocol for management of the Nurse Advice line. To perform this job, an individual must successfully perform each essential duty. 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. This job description is not intended to be all-inclusive; employees will perform other related business duties as assigned by the immediate supervisor and/or hospital administration as required.

• Always maintains utmost level of confidentiality.
• Adheres to Health System and Health Plan policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Demonstrates a high degree of independence, flexibility, initiative, and commitment.
• Identifies documentation discrepancies, gathers, compiles, and evaluates data from various sources, and audits for reporting to internal leadership and external agencies.
• Assists in data capture, analyzing, identifying trends/concerns, and preparing recommendations for improvements as indicated in analyzed data.
• Performs internal PH Operations audits and/or trend assessments to identify opportunities for improvement.
• Assist in the evaluation of the effectiveness of PH Operations projects/initiatives within DHP in conjunction with Program and work plans.
• Performs PH activity audits, makes recommendations as needed.
• Creates and provides training related to relevant PH Operations leadership and management regarding processes and initiatives for DHP staff.
• Ensures the integrity of project data, including data extraction, processing, storage, manipulation, analysis, and distribution.
• Works with management to develop statistical analysis that address proposed projects and analyzes data using basic statistical methods, interprets results and provides written summaries of analyses on short notice and with timely turnarounds.
• Maintain, generate, and participate in the development of PH Operations metrics dashboards.
• Serves as an expert on clinical data abstraction/interpretation.
• Provides departmental training for both new hire and annual refreshers for staff.
• Serves as SME for Complaints process as well as utilizing data from complaints to provide insight into training topics to be developed and delivered.
• Knowledgeable of covered, and non-covered such as, non-capitated services; community and social service resources; and community-based case management services for which all lines of business may be eligible.
• Will provide Nurse Triage services for Nurse Advice Line (NAL) during business hours and after-hours utilizing software and protocols as required.
• Will provide on-call cover for NAL as assigned.
• Performs other duties as requested.

Education And/Or Experience:

• Minimum- Associate's degree in nursing, related equivalent field.3-5 years related experience and/or training;
• Or equivalent combination of education and experience.
• Proficiency in Microsoft Office suite including Word, PowerPoint, Excel, Visio

Certificates, Licenses, Registrations:

• Current unrestricted Registered Nurse Licensure in the state of Texas-if applicable

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