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Quality Improvement Accreditation Project Manager

Company: MedStar Health's Washington Hospital Center
Location: Baltimore
Posted on: February 25, 2021

Job Description:

COVID-19 Update:--Many of the photos on our career website were selected prior to the COVID-19 pandemic. All patients and providers are expected to follow the current MedStar Health guidelines for safety including proper masking and physical distancing where appropriate. Learn more

MedStar Health is committed to the health and safety of our patients, associates, and communities. To keep personal information safe, we encourage all applicants to take the necessary steps to protect themselves against fraudulent activity. MedStar Health uses various platforms to communicate with applicants, however MedStar Health representatives will only use official MedStar Health--email addresses (ending in "" or ""). Any messages sent from any other email addresses are not genuine. Learn more Quality Improvement Accreditation Project Manager Job Id 40380 Category Nursing MedStar Family Choice Department Utilization-Quality Mgt Location Baltimore, MD Full Time Day Shift Are you currently a MedStar Health associate? If you are currently employed by MedStar Health, please apply here.

  • Job Summary
    • Responsible for managing all NCQA and SPR (System Performance Review) survey / audit preparation functions, managing the survey / audit process, preparing, and educating MFC staff for surveys. Responsible for coordinating the organization and the collection of survey materials from the MFC staff and producing all necessary materials for NCQA Accreditation/Surveys and SPR audits and surveys. Acts as a liaison between departments and the NCQA consultant, NCQA ASC / surveyors, and EQRO (External Quality Review Organization) surveyors for SPR audit. Defines audit / survey objectives and oversees quality control throughout the project /event life cycle and coordinates meetings effectively across all departments within MFC. Develops and manages all educational materials and standard operating procedures regarding SPR and NCQA Accreditation in conjunction with the NCQA consultant where applicable. Assists with the planning and developing of projects pertaining to SPR audits and NCQA Accreditation surveys.
    • Minimum Qualifications
      • Education/Training
        • Bachelor's Degree in Nursing, Health Administration or other health related field. Master's Degree in Nursing, Healthcare Administration, Business Administration, or health related field preferred.
        • Experience
          • 5 years of healthcare experience required. 3-5 years of managed care or health plan experience required. Prior NCQA submission experience required. Project management experience preferred.
          • License/Certification/Registration
            • Valid RN license or certification in a healthcare field where applicable. Certified Professional in Healthcare Quality (CPHQ) preferred. Project Management Professional (PMP) certification preferred.
            • Knowledge, Skills & Abilities
              • Excellent written and verbal communication skills. Ability to follow verbal and written instructions. Attention to detail and ability to meet strict deadlines. Team player and the ability to influence others. Ability to operate effectively across organizational boundaries. Strong organizational abilities focusing on event management in a fast-paced environment. Proficient with Microsoft Office applications, especially Word, PowerPoint, and Excel. Proficient with Adobe Acrobat Pro with ability to learn and apply additional software. Knowledge of current trends in health care delivery and population health.
              • Primary Duties and Responsibilities
                • Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
                • Serves as project lead to coordinate and manage overall project milestones, deliverables, logistics, and production timelines to meet strict regulatory deadlines and ensure overall successful execution for all SPR and NCQA audits. Coordinates all survey / audit functions and manages the survey / audit process from beginning to end.
                • Effectively communicates project expectations to MFC Senior Leadership Team (SLT) and responsible parties in a timely and clear manner. Acts as a liaison between MFC SLT and NCQA consultant / EQRO contacts when applicable. Identifies and reports any potential accreditation related issues or concerns to appropriate personnel.
                • Takes initiative to determine appropriate action and resolution of various day to day matters, issues, and projects when determined to be within scope of authority.
                • Assists with the development of department-specific documentation as it relates to NCQA accreditation standards / guidelines and SPR audits pertaining to COMAR requirements.
                • Audits MFC documentation in accordance with applicable NCQA Standards and/or SPR / COMAR requirements making appropriate recommendations to management and leadership as needed.
                • Develops and coordinates trainings with applicable departments related to accreditation activities on an as-needed basis.
                • Plans, organizes and leads MFC Policy Workgroup and reports to QI/UM Committee upon annual review and updates when applicable. Participates in developing policies and procedures required for accreditation.
                • Ensures existing MFC policies and procedures are in compliance with both COMAR and NCQA standards and ensures that they are refined as the standards change.
                • Assists with the development and maintenance of MFC's QI program via input with the annual QI plan and appraisal.
                • Generates preliminary Quality Improvement Activity documents required for submission and distributes them to appropriate MFC staff for completion.
                • Creates, presents, and/or submits documents, reports, and materials in a timely and accurate manner to applicable MFC committees.
                • Oversees the life cycle of Performance Improvement Projects (PIP's) mandated by the State and other pertinent Quality Improvement Activities.
                • Leads NCQA workgroups and performs mock surveys in non-audit years. Prepares survey team members for surveys and mock surveys.
                • Maintains current knowledge of the NCQA Accreditation Standards and COMAR. Reviews annual updates and FAQs. Notifies department heads of NCQA and COMAR changes and assists with development plan for operationalizing these updates.
                • NCQA: Manages the survey reporting process through all stages of review and submission by completing and submitting the web-based tool and pre-site SSME grid; preparing for on-site surveys, reviewing information submitted by managers and survey team members for validation of the standard, preparing for and conducting survey conference calls, and communicating pertinent information to survey team as needed.
                • EQRO/SPR: Manages the audit process through all stages of the review and submission by completing and submitting all documents through the portal, preparing for on-site audits, reviewing information submitted by responsible parties as needed.
                • Oversees and directs accreditation and SPR audit activities for the Medicaid health plans. This includes developing a project plan of deliverables and keeping management informed of progress.
                • Participates in the implementation and effectiveness of related procedures and programs developed to maintain NCQA Accreditation. Participates in the implementation and effectiveness of related procedures and programs developed to maintain NCQA Accreditation. Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.
                • Performs other duties as assigned. About MedStar Health
                  MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment. Enter your email address to sign up for career opportunity alerts. Enter Email address Get tailored job recommendations based on your interests. 10980 Grantchester Way Columbia, MD 21044

Keywords: MedStar Health's Washington Hospital Center, Baltimore , Quality Improvement Accreditation Project Manager, Executive , Baltimore, Maryland

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