Manager - Corporate Quality Manager

COMMUNITY HEALTH GROUP•Chula Vista, CA

17d

About The Position

Under the direction of the Director of Corporate Quality, manages the day-to-day operations of the Corporate Quality Department including the areas of grievances and appeals (G&A), the identification, resolution, and tracking of potential quality issues (PQIs), facility and medical record reviews, Health Effectiveness Data and Information Set (HEDIS) file review and clinical oversight, and quality reporting. Serving in a clinical and operational role, supports the provision and access to quality health care and member advocacy. The Manager is expected to step in and perform critical departmental tasks as needed to ensure operational continuity and timely completion of responsibilities when team members are unavailable or when priorities demand additional support.

Requirements

5 years of professional work experience in healthcare
2 or more years or equivalent in supervision
Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum
Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas and the ability to present confidently in group settings
Organizational skills with the ability to handle multiple tasks and/or projects at one time
Customer service skills with the ability to interact professionally and effectively with providers, physicians, and staff from all departments within and outside CHG
Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization
Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements
Problem solving skills with the ability to look for root causes and implementable, workable solutions
Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs
Track record of producing work that is highly accurate and demonstrates attention to detail
Must be able to lift and/or move up to 10 pounds and have close vision

Nice To Haves

Quality management experience preferred
Current, unrestricted RN license in California, preferred

Responsibilities

Upholds Community Health Group’s (CHG’s) quality improvement and health equity program according to standards and requirements promulgated by the Department of Managed Health Care (DMHC), the Department of Health Care Services (DHCS), the National Committee for Quality Assurance (NCQA), the Centers for Medicare and Medicaid (CMS), and based on evidence-based standards of practice.
Supervises the Corporate Quality Nurses, the Grievances and Appeals Supervisor, the Corporate Quality Specialists in the performance of their role and position description.
Oversees and provides guidance and assistance to the clinical and non-clinical staff to meet individual and departmental performance goals, metrics, and regulatory requirements.
Maintains and develops departmental policies, procedures, desk references, job aids, and guidelines under the direction of the Director of Corporate Quality.
Develops, produces, validates, and submits regulatory and management reports directly or in collaboration with staff.
Oversees CHG’s facility and medical record review process in accordance with DHCS along with CHG’s DHCS-certified Master Trainers.
Oversees CHG’s grievance and appeal process in accordance with regulatory and accreditation standards and advocates on behalf of members to appropriately identify and address potential quality issues in accordance with established policies, procedures, and standards.
Oversees the complete and timely investigation and resolution of potential quality issues and the implementation and follow-up of corrective actions when indicated.
Provides analytical support to clinical programs; performs clinical assessments and clinical audits and file review as necessary to support the Corporate Quality Department responsibilities including HEDIS-related activities.
Assists the Director of Corporate Quality in producing internal and/or external management and regulatory reports.
Trains staff and providers
Ensures company compliance with regulatory guidelines by participating in the preparation process required for regulatory and accreditation audits and assisting with the implementation of corrective action plans.
Can do the work of direct reports if necessary, due to absences or during spikes in volume.
Is responsible for the operations of the department in the absence of the director.
And all other duties assigned by the department director.