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Quality Management Specialist II in Coral Gables, FL at Beacon Health Options

Date Posted: 2/5/2019

Job Snapshot

Job Description

We are currently seeking a dynamic Quality Management Specialist II to join our team at our office in Miami, FL.  The experienced quality management professional will have a strong clinical focus to provide monitoring and investigation of complaints, quality of care, adverse incidents and critical incidents.  Support clinical and quality process improvements to meet NCQA requirements, including HEDIS® improvement activities.

Duties and Responsibilities

  1. Supports key aspects of NCQA accreditation and other regulatory requirements including but not limited to:

    1. Knowledge of the standards

    2. Working with the team to meet or/ & exceed the standards and

    3. Regulatory requirements

    4. Maintenance of necessary and relevant documentation history

    5. Completion of NCQA documentation requirements

  2. Manages complaint, quality of care, adverse incident and critical incident reporting and investigation process to ensure compliance with corporate policies, client, regulatory and accreditation standards.

  3. Serves as a liaison to Health Plan clients related to complaints, quality of care, adverse incidents and critical incidents

  4. Tracks complaints, quality of care, adverse incidents and critical incidents and creates reports for Health Plan clients and regulatory/accreditation entities.This includes internal document tracking and executive summaries that describe barriers, results, operational strengths, interventions, opportunities for improvement and recommendations.

  5. Provide ongoing support for accreditation survey preparation.

  6. Serves as an internal consultant for service center identification and reporting of complaints, quality of care, adverse incidents and critical incidents.

    1. Consultation to clinical and customer service staff as well as assistance with training

    2. Working with the Medical Director and clinical contacts as additional resources for clinical review

    3. Reviews and makes changes as required for relevant policies, procedures and workflows related to complaint, quality of care and incidents for reporting and investigation

  7. Participates in internal and external Quality Management Committees or Workgroup activities. This includes Provider Review Committee and Regional Quality of Care Committee.

  8. Provides review and analysis for various QM activities including but not limited to:

    1. Quality of Care Cases

    2. Adverse Incidents and Critical Incidents

    3. Treatment Record Review

    4. Access and availability

  9. Works closely with Clinical Operations, Customer Service, Account Management and Provider Relations at a local level to ensure comprehensive, efficient and integrated systems that ensure communication and positive outcomes.

  10. Performs other duties as assigned.

Minimum Entry Level Qualifications

Bachelor’s Degree required in one of the following related fields: QM, Psychology, Behavioral Health, Statistics or RN with relevant QM or Managed Care Experience. Master degree preferred.

Licensure: Clinical License (LMHC, LMFT, RN, LCSW, etc.) preferred, but not required

Years and Type of Relevant Work Experience:

3-5 years Quality Management experience required. 5 years of experience in Utilization Management or Quality Management if not licensed (LMHC, LMFT, RN, LCSW, etc.)


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Beacon Health Strategies, LLC., a Beacon Health Options company, is proud to be an Equal Opportunity Employer as well as a Drug Free Work Environment. EOE/M/F/Veterans/Disabled






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