RN Quality Assurance Manager, Clinical Systems

CareOregon•Portland, OR

10d•$140,940 - $172,260•Remote

About The Position

This position is responsible for providing leadership oversight in the correct and effective use of decision tools used for utilization management activities including staff training. The position is responsible for managing multiple teams and resources. They work collaboratively with Clinical Operations and other CareOregon Teams to ensure integration and support of organizational activities and goals across all lines of business. The position is responsible for department planning, as well as developing, implementing and managing internal operations and vendor transactional quality assurance processes, reports, dashboards and workflows to ensure CareOregon’s quality standards are achieved, and compliance requirements are met. Additionally, the role is responsible for communicating results, process improvements and remediation outcomes both laterally and horizontally.

Requirements

Current unrestricted Registered Nurse (RN) license for State of Oregon
Minimum 5 years’ experience in health plan quality operations, such as member rights, quality assurance, and/or utilization management
Strong knowledge of health plan operations
Knowledge of health plan regulatory requirements of Medicaid and Medicare managed care
Knowledge of utilization management principles
Knowledge of managed care concepts and principles
Knowledge of organizational improvement principles and practices
Knowledge of principles of organizational change and ability to act as a change agent
Knowledge of quality improvement concepts, principles and practices
Excellent written and verbal communication skills
Ability to work independently and as part of a team
Strong attention to detail and organizational skills
Ability to manage multiple projects and meet deadlines
Basic understanding of software development phases
Comprehensive skills in program development, management and evaluation
Strong project management skills
Strong statistical, analytical and problem-solving skills
Ability to determine root problems
Ability to create test requirements
Strong detail-orientation, prioritization and organization skills
Ability to work well under pressure in a complex and rapidly changing environment
Self-motivated, adaptable to change and forward-thinking attitude
Excellent spoken, written and presentation communication skills
Excellent interpersonal skills
Excellent leadership skills including the ability to coach, mentor and inspire staff working both onsite and remotely
Skill in negotiation and conflict resolution
Skill in collaboration and consensus building between and within departments
Ability to lead and influence change and results
Ability to work effectively with diverse individuals and groups
Ability to maintain positive and professional relationships as a role model, leader and representative of CareOregon
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day

Nice To Haves

Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program
Proficiency with nationally accepted clinical guidelines, such as InterQual or MCG
Experience developing quality and testing programs, processes and procedures from the ground up
Experience with applications and front and back-end system testing & technologies in multiple operating systems and environments
Experience in clinical content creation or medical writing
Experience with training and onboarding
Experience directing vendor testing

Responsibilities

Develop and oversee implementation of (department) policies and procedures.
Develops and oversees training documents, audit materials and educational resources.
Conduct process trainings.
Assist the Director in long- and short-term quality planning.
Assure clinical systems align with regulatory and contractual requirements (Medicare and Medicaid) and organizational needs.
Design, develop, and update clinical content through the review and understanding of information gathered from regulatory and organizational requirements.
Develop Quality Assurance testing of clinical content and create and maintain documentation.
Create and maintain tools and processes to verify accuracy and effectiveness of clinical systems.
Analyze data and information to identify improvement opportunities and recommend changes/enhancements to processes.
Develops and implements strategies to ensure compliance with internal and external plans of correction.
Maintains records that demonstrate compliance with regulatory requirements and/or plans of correction.
Keep abreast of regulatory expectations (state, federal and health plan) and inform staff and other stakeholders of these requirements.
Keep abreast of standards for health plan quality operations related to responsible areas and develop plans to operationalize.
Utilizes Quality Improvement methodologies as part of continuous improvement including root cause analysis, Plan/Do/Study/Act.
Utilizes change management methodologies to communicate required changes to staff and other teams.
Prepare internal business reviews and presentations as needed.
Maintain up-to-date knowledge of clinical practices and Medicare and Medicaid guidelines.
Serve as a clinical resource for both internal and external customers, including training of new content both created and as part of the product.
Collaborate with Medical Directors and Clinical Operations leadership team for organizational criteria
Develop project plans, monitoring tasks and ensuring on-time delivery of clinical content.
Works collaboratively with other CareOregon leaders and departments.
Participates in internal and external workgroups/meetings as required.
Assures stakeholders are engaged in performance improvement processes.
Develops a matrixed relationship with other Quality Assurance Leaders as necessary to assure efficient departmental functioning.
Provides cross coverage for other departmental leaders.
Assists in internal and external audits are requested.
Manages team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
Train, supervise, motivate, and coach employees; provide support toward employee development.
Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
Utilize CareOregon’s competencies to evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
Perform supervisory tasks in collaboration with Human Resources as needed.
Perform work in alignment with the organization’s mission, vision and values.
Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
Strive to meet annual business goals in support of the organization’s strategic goals.
Adhere to the organization’s policies, procedures and other relevant compliance needs.
Perform other duties as needed.

Benefits

competitive pay
bonus opportunity
medical insurance
dental insurance
vision insurance
life insurance
AD&D insurance
disability insurance
health savings account
flexible spending account(s)
lifestyle spending account
employee assistance program
wellness program
discounts
multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
strong retirement plan with employer contributions
Paid State Sick Time
paid holidays
volunteer time
jury duty
bereavement leave