Manager, Quality Improvement

Job Description

Job Description

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

Remote position; must reside in California.

What You Will Be Doing :

Under general supervision, the Manager of Quality Improvement is responsible for developing and implementing department business plans and overseeing resources and department operations in a manner that ensures regulatory and accreditation compliance and meets best practices.

Work is varied and moderately complex and requires a moderate degree of discretion and independent judgement.

Our Vision :

Continuously improve the health of our community.

Our Mission :

We provide healthcare value and advance wellness through community partnerships.

Essential Functions :

• Develops unit goals based on established objectives, participating with peers to ensure effective integration; develops and implements associated action plans.
• Plans and assigns work; makes timely and effective adjustments as required.
• Monitors and analyzes metrics, including but not limited to regulatory activities, clinical and practitioner data; makes recommendations and implements action plans based on findings.
• Works to develop internal programs geared at continuous tracking, and trending of quality issues.
• Anticipates the need for and develops and implements relevant and effective programs, policies, procedures, and processes for the core quality program based on regulatory requirements, opportunities, issues, and trends.
• Collaborates with medical management and other departments to ensure that the Quality program meets or exceeds NCQA and regulatory standards.
• Collaborates with internal and external stakeholders to develop programs that increase awareness and provide educational opportunities to providers and members regarding HPSJ / MVHP’s Quality Improvement program goals and activities.
• Collaborates with the HEDIS team, Provider Services, and other internal and external stakeholders to ensure effective implementation of provider and member interventions to improve quality and HEDIS measures.
• Conducts the preparation, implementation, and corrective action plans for internal and external audit activities to ensure practices adhere to NCQA and regulatory standards of both DHCS & DMHC and CMS.
• Works closely with the network providers to improve the quality of care and service provided to the members, with a focus on improving MCAS performance and with appropriate submission of encounter data.
• Develops or oversees the development of relevant, timely and accurate internal and external quality reports, advising leadership as appropriate.
• Develops, implements, and maintains appropriate and required records, documents, policies, and procedures; collaborates with internal and external stakeholders to ensure the collection, storage and retrieval of relevant data and information.
• Participates in internal and external committees as required.
• Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission, and values.
• Hires, develops, and retains, and ensures that subordinate managers hire, develop, and retain competent staff.
• Oversees or conducts root-cause analysis investigations for specific patient care and network provider trends and all adverse effects;

makes recommendations and implements action plans based on findings.

• Performs and oversees Facility Site Reviews and Medical Record Reviews.
• Assists in the development of department budget; manages budget for area of responsibility.
• Compiles, develops, and submits or oversees the compilation, development, and submission of internal and external quality reports.
• Proactively assists the department to prepare and build programs to monitor and address health disparities as they relate to the Quality Programs and Interventions to comply with regulatory & NCQA standards.
• Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategies, vision, mission, and values.
• Hires, develops, supervises, and retains an adequate and competent staff.

What You Bring :

Knowledge, Skills, Abilities and Competencies

Required

• Strong clinical skills.
• In-depth knowledge of federal and state laws, standards, and regulations, including DMHC, DHCS, Medi-Cal and / or Medicare and HIPAA, as they related to quality in managed care organizations.
• In-depth knowledge of the principles and best practices of quality improvement, including but not limited to metrics and corrective action plans.
• In-depth knowledge of the healthcare issues affecting the underserved.
• Basic knowledge of the business, economic, demographic, and political trends and developments affecting managed care, Medi-Cal and / or Medicaid.
• In-depth knowledge of audit processes, including state audit processes, and ability to effectively implement and maintain them.
• Financial acumen : Interprets and applies understanding of key financial indicators to make better business decisions.
• Manages complexity : Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
• Decision quality : Makes good and timely decisions that keep the organization moving forward.
• Strategic mindset : Sees ahead to future possibilities and translates them into breakthrough strategies.
• Strong analytical skills, including the ability to identify relevant metrics, draw conclusions and take action based on results.
• Ability to develop and execute goals and associated business plans.
• Resourcefulness : Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
• Plans and aligns : Plans and prioritizes work for self and others to meet commitments aligned with organization goals.
• Ensures accountability : Holds self and others accountable to meet commitments.
• Drives results : Consistently achieves results, even under tough circumstances.
• Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
• Strong oral and written communication skills, including the ability to communicate professionally to diverse individuals and groups inside and outside of HPSJ, effectively explain complex information, and develop workflows, policies, and procedures.
• Strong presentation skills, including but not limited to the ability to tailor presentations to specific audiences, and identify key messages.
• Persuades : Uses compelling arguments to gain the support and commitment of others.
• Collaborates : Builds partnerships and works collaboratively with others to meet shared objectives.
• Situational adaptability : Adapts approach and demeanor in real time to match the shifting demands of different situations.
• Being resilient : Rebounds from setbacks and adversity when facing difficult situations.
• Ability to develop and deliver relevant and effective training and supporting materials.
• Strong knowledge of change management theory, with the ability to implement effectively.
• Strong project management skills and demonstrated ability to lead complex initiatives.
• Intermediate skills in Windows, Word, Excel, PowerPoint, and Outlook.
• Demonstrated ability to articulate and support HPSJ’s vision, mission, values, and strategy, integrate into management practices, and foster their manifestation among staff.
• Demonstrated ability to supervise staff in a manner that maximizes employee performance and business results.
• Ability to handle confidential information with appropriate discretion.
• Ability to speak and be understood in English.

What You Have :

Education and Experience

Required

• Graduation from an accredited nursing school; and
• Bachelor’s degree in nursing, business management or related fields; and
• At least five years in quality improvement and / or disease management in a healthcare setting; and
• At least five years supervisory experience in a healthcare setting; or
• Equivalent combination of education and experience
• Experience in an HMO or managed care setting.

Preferred

• Experience in QI for government sponsored programs.
• Experience in HEDIS record collection and risk adjustment.

Licenses, Certifications

Required

• Current unrestricted California RN license relevant to the field of specialization.
• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.

What You Will Get : HPSJ Perks :

HPSJ Perks :

• Competitive salary
• Robust and affordable health / dental / vision with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven our members and community are at the core of everything we do.
• A shorter commute if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety you have a chance to work with people at all levels of the organization, and work on diverse projects.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve.

Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws.

It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.

Important Notice : This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.