Manager, Provider Quality Oversight

Inland Empire Health Plan•Rancho Cucamonga, CA

2d•Remote

About The Position

Overview What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! At Inland Empire Health Plan (IEHP), we believe the highest quality of care should be delivered to all in the Inland Empire. We are thinking beyond the way Quality is viewed today – we believe it should be holistic and transformative. IEHP’s provider incentive programs serve an important role in achieving IEHP’s quality goals. Reporting to the Director of Quality Management, the Manager of Provider Quality Oversight is responsible for: Leading the daily operations of the Potential Quality Incident/Provider Preventable Condition and clinical reporting nurse teams. The daily activities and functions of their responsible areas to include but not limited to the management, evaluation, mentoring, and coaching of Team Members. Ensure the complete review of Quality-of-Care cases, adherence to standard work, reporting accuracy, and compliance with IEHP policies, Local, State, and Federal laws, and regulations. The planning and implementation of any quality audit initiatives, programs, and processes identified by IEHP’s Quality System. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more. CalPERS retirement 457(b) option with a contribution match Generous paid time off- vacation, holidays, sick State of the art fitness center on-site Medical Insurance with Dental and Vision Paid life insurance for employees with additional options Short-term, and long-term disability options Pet care insurance Flexible Spending Account – Health Care/Childcare Wellness programs that promote a healthy work-life balance Career advancement opportunities and professional development Competitive salary with annual merit increase Team bonus opportunities

Requirements

Five (5) or more years of any individual or combined healthcare experience in quality management, quality assurance, quality improvement, utilization management, case management, acute care, and/or ambulatory care setting
Three (3) or more years of experience in a supervisory or leadership role in any healthcare setting
Bachelor’s degree in Nursing from an accredited institution required
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required
Knowledge of clinical audits, including medical record reviews
Intermediate knowledge of word, excel, and PowerPoint.
Intermediate computer skills
Excellent verbal and written communication skills
Builds effective work relationships

Nice To Haves

Experience in an HMO or Managed Care setting is preferred
Master’s degree in Nursing from an accredited institution preferred
Certified Professional in Healthcare Quality (CPHQ) certification preferred

Responsibilities

Responsible for managing direct reports to ensure effective resource management and prioritization of work in support of meeting Quality and Organizational goals and priorities.
Responsible for the development, management, implementation, and evaluation of all areas of responsibility including, but not limited to, Potential Quality Incidents (PQI)/Provider Preventable Conditions (PPC) processes, Quality Reviews, and clinical audits of IEHP Providers to ensure clinically appropriate billing.
Provide oversight and management of the PQI and PPC processes and staff to comply with IEHP policies, Local, State, and Federal standards, and regulations.
Collaborate with appropriate internal and external departments, team members, and entities to achieve organizational quality initiatives, as assigned.
Responsible for the development, maintenance, implementation, and adherence to departmental policies and procedures, standard operating procedures, and job aides.
Participate in Quality Management activities and projects to ensure interventions meet project goals. Participation also includes compiling results and presenting a report to the Director of Quality Management, regulators and/or IEHP committees as appropriate.
Lead, prepare, and coordinate appropriate Provider Quality Review department related internal meetings.
Represent IEHP in external meeting related to key areas of responsibility as appropriate.
Any other duties as required to ensure the Health Plan operations are successful.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance.
Establish and maintain effective working relationships with others throughout the organization.