Manager Quality Management

Jefferson Health Plans • Philadelphia, PA

2d

About The Position

The Manager, Quality Management (QM) oversees the QM team who investigates and documents cases for quality of care (QOC) referrals and complaints received by the QM Department. Coordinates the provider office visits, when warranted, based on quality measures and educate providers on pay for performance, HEDIS and quality based measurement. Oversee the STAR HEDIS Audit Specialist activities. Performs HEDIS chart over reads and seasonal training and oversees the QM department key indicator reporting and trending. Oversee the QM Audit team's quality medical record review to ensure continuum of care management effectiveness and to report to the PCP potential gaps and adherence issues against clinical, HEDIS, STARS and other regulatory objectives

Requirements

• Specialized Diploma in Nursing
• 5 years experience in quality management monitoring activities including credentialing and quality case reviews is required.
• Experience in the development, implementation, and evaluation of quality management activities in an acute or ambulatory setting is required.
• Excellent verbal and written communication skills are required.
• Ability to present and discuss clinical quality of care issues with the QM team, Director, Medical Director and Assistant Vice President (AVP), Quality Improvement and Performance is required.
• Strong analytical and problem solving skills are required.
• Strong organizational skills and ability to manage multiple priorities are required.
• Ability to function independently with minimal supervision is required.
• Basic understanding of QM principles is required.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania

Nice To Haves

• Bachelor’s Degree in Nursing
• Managed care experience is preferred
• Knowledge of NCQA, DPW and CMS standards are preferred.
• Basic computer skills in Outlook, MS Word, Excel and SharePoint preferred.
• Valid driver’s license and auto insurance preferred.

Responsibilities

• Ensures QOC investigations are completed timely
• Anticipate and identify causes of interruption in unit functions and takes appropriate action to meet performance expectations.
• Promptly report to Director when staffing changes or external influences will negatively impact unit performance.
• Coordinate QM team work to adjust assignments to insure meeting departmental goals.
• Communicate with Medical Director, Department Director and VP issues regarding QOC and HEDIS/STARS activities
• Makes recommendations for further provider education based on findings and collaborates with the management team and medical directors to develop education approaches to improve care.
• Reports QOC issues to the Credentialing Committee
• Provide updates at the Quality Improvement Committee based on QOC trends
• Assist on focused study audits to measure plan performance.
• Oversee and participate in practitioner medical record review process for HEDIS, PA Performance Monitoring, External Quality Review (EQR) and other regulatory or QM related activities.
• Maintain databases and spreadsheets to track and trend quality monitoring activities, results and outcomes.
• Maintain accuracy and timeliness in database management.
• Oversee the interrater testing and/or monitoring of the staff regarding QOC, HEDIS and EQR.
• Ensure Provider Quality Profile Dashboard is up to date and work with MircoStratigies to make enhancements
• Contribute to the development and enhancement of documentation, tracking and audit tools and process flows for quality monitoring activities as assigned by the Director.
• Orients new staff to duties and responsibilities; maintain documentation associated with orientation.
• Participate in workgroups tasked with performing barrier analysis for quality of care and quality of service activities as assigned.
• Oversee and contribute to the NCQA accreditation survey prep and ensure all relevant standard documents are complete and prepared for review.
• Manage cross-functional employees to meet and exceed service requirements and functional objectives.
• Monitors EMR access for facilities and providers
• Works closely with other units in the Medicare STARS departments for HEDIS, STARS and ad hoc initiatives
• Recruit, develop, motivate and retain a high caliber of team members
• Interpret and use care management clinical assessments and notes for relevancy, appropriateness of findings and clinically sound judgment as part of the medical review process.
• Build and administer a business plan, control expenses, and increase profitability to meet established business goals.
• Coach and lead team to continuously improve operational performance.
• Maintain a positive work environment that supports self-direction; provide a structure to optimize experience, skill, knowledge and capability of the team.
• Reward team members based on contribution and performance.
• Maintain and foster a collaborative relationship with internal and external customers.
• Manage budget and control expenses while meeting operational, financial and service requirements.
• Perform all other duties as assigned.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.
• For more benefits information, please click here

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree