Clinical Quality Specialist

Role Overview

The Clinical Quality Specialist supports the Office of Medicaid Policy and Planning (OMPP) by overseeing quality assurance, regulatory compliance, and performance improvement across all Indiana Medicaid programs which include Hoosier Healthwise, Healthy Indiana Plan (HIP), Hoosier Care Connect, PathWays for Aging, and Fee-for-Service Medicaid. You will ensure that quality strategies are data-driven, equitable, and aligned with federal and state standards to improve health outcomes for all Hoosiers. You will be responsible for quality oversight of vendors and partners working in the clinical space of Indiana Medicaid, including Managed Care Entities (MCEs) and Fee for Service vendors. You will be responsible for aligning efforts in conjunction with state laws and rules as well as federal requirements. The role entails considerable amounts of public-speaking, problem-solving, research, negotiation, collaboration, and some in-state travel.

The ideal candidate in this role should minimally have either: a Registered Nurse (RN) License plus three (3) years of experience, or a Licensed Practical Nurse (LPN) License plus five (5) years of experience, or an Associates Degree in a clinical discipline plus seven (7) years of experience, or at least ten (10) years of experience in a clinical setting applying the knowledge, skills, and abilities as listed in the 'What You'll Need for Success' section of the Job Profile. Experience with qualitative and quantitative analysis tools, CMS quality measures and NCQA standards strongly preferred. Experience in healthcare quality, contract oversight, audit processes, Medicaid policy, or public health analytics strongly preferred. Clinical experience in managed care strongly preferred.

A Day in the Life

The essential functions of this role are as follows:

• Establish, monitor, and implement long-range objectives and specifying the strategies, KPIs, and actions to achieve them.
• Analyze operations to evaluate performance of the specific program or its staff in meeting objectives or to determine areas of potential cost reduction, program improvement, or policy change.
• Interpret and explain in-depth and complex policies, rules, regulations, or laws to organizations, government or corporate officials, or individuals.
• Develop and implement corrective action plans to solve organizational or departmental problems.
• Prepare and present reports for approval, including those for funding or implementation of services to executive leadership.
• Develop and oversee program financial or budget activities to fund operations, maximize investments, or increase efficiency.
• Develop and monitor program requirements to ensure it meets federal and state policies and grants compliance.
• Develop and supervise training of employees and consultants on program requirements and usage.
• Develop, coordinator, and deliver communication plans and communications.
• Preside over, or serve on, boards of directors, management committees, or other governing boards.
• Recruit, select, onboard, and train employees to ensure role responsibilities and expectations are clearly understood while providing opportunities to continue professional development.
• Set expectations, measure progress, provide ongoing feedback, and evaluate the performance of employees. Ensure work adheres to quality standards, deadlines, and proper procedures.

The job profile is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.

This position is exempt from overtime compensation for additional work hours which may be required to complete essential functions or other assigned work. Exempt employees may work more than 75 hours in a pay period without additional compensation and must report a minimum of 75 hours per pay period of work hours and/or paid leave taken to receive their base biweekly salary.