Quality Improvement Accreditation Project Manager
Company: MedStar Health's Washington Hospital Center
Posted on: February 25, 2021
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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
- 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
- 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.
- Valid RN license or certification in a healthcare field where
applicable. Certified Professional in Healthcare Quality (CPHQ)
preferred. Project Management Professional (PMP) certification
- 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
- 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
- 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
- Oversees the life cycle of Performance Improvement Projects
(PIP's) mandated by the State and other pertinent Quality
- Leads NCQA workgroups and performs mock surveys in non-audit
years. Prepares survey team members for surveys and mock
- 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
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Columbia, MD 21044
Keywords: MedStar Health's Washington Hospital Center, Baltimore , Quality Improvement Accreditation Project Manager, Executive , Baltimore, Maryland
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