QI Specialist at Avalon Healthcare Solutions in Tampa, FL

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Description


QI Specialist

US-FL-Tampa

Job ID: 2019-1165
Type: Regular Full-Time
# of Openings: 1
Category: Medical Policy
Avalon Healthcare Solutions

Overview

About the Company:

Avalon Healthcare Solutions, headquartered in Tampa, Florida, is a clinical services and information technology company using evidence-based medicine to develop and deploy medical policies and protocols in the high-volume, dynamic and complex diagnostic lab environment. The company manages the appropriate use of thousands of existing lab tests and researches new tests to determine efficacy and impact on patient care.

Studies show that 30% of clinical laboratory testing is unnecessary or overused. Inappropriate testing or missing a key screening can lead to complications and expense arising from unwarranted care, or not obtaining proper care when needed, leading to increased health risks and costs. Avalon helps ensure delivery of the right test, at the right time, and in the right setting. We seek to ensure the most effective patient treatment, improve clinical outcomes, and optimize cost and affordability.

Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabled service companies. Since its launch 15 years ago, FP has raised approximately $10 billion and invested in more than 150 companies.

Avalon is a high growth company where every associate has an opportunity to make a difference. You will be part of a team that shapes a new market and business. You’ll enjoy seeing the results of your work as we rapidly implement our plan. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.

For more about Avalon, please visit our web site at http://www.avalonhcs.com.

About the Nurse Reviewer/QI Specialist Position:

This position is a dual function position. The person in this position will split their time equally between prior authorization review and QI activities.

This position is based in Tampa, Florida, and is not a remote role. This is a full-time, W-2 position. At this time, we can consider only local candidates authorized to work in the US. No sponsorship is available. No recruiter calls, please.



Responsibilities

Nurse Reviewer/QI Specialist - Essential Functions and Responsibilities:

  • Reviews prior authorization requests using health plan policies and determines if medical necessity criteria are met.
  • Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, and helpfulness.
  • Develops and maintains annual QI Work Plan document.
  • Monitor required QI Work Plan metric trends, identify variation, convene functional area or cross-functional teams as needed to conduct root cause analysis and institute meaningful action to achieve defined performance goals.
  • Schedules quarterly QIC meeting and develops and disseminates agenda and meeting minutes.
  • Lead and facilitate QI functions, such as those associated with client health plan delegation oversight, and the annual QI, UM operational policy review and revision.
  • Manage and monitor clinical quality studies that may be undertaken by Avalon, to include receipt and analysis of trended data, assessment of national benchmarks as available, development of improvement recommendations (to include ROI and best practice interventions as appropriate), presentation to senior leadership, implementation of plan, and evaluation for desired result.


Qualifications

Nurse Reviewer/QI Specialist - Qualifications:

  • Three (3) years’ experience in utilization review, physician review services and/or a prior authorization inbound call center and five (5) years of health care quality improvement experience in a managed care or health care services vendor relationship setting.
  • Bachelor of Science in Nursing (BSN) required
  • Ability to apply clinical judgment where appropriate.
  • Current active, unrestricted RN license.
  • Willing and able to work 8:30 AM – 5:30 PM in our corporate office Monday through Friday.
  • Attend and participate in meetings via phone, computer, or in person.
  • Proficient in MS Office.

Nurse Reviewer/QI Specialist - Preferred Qualifications/Skills

  • Working knowledge of NCQA UM accreditation requirements.

PM18


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