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Provides leadership and oversight for day-to-day operations of the quality improvement coordination staff including the overall coordination and supervision of activities as it relates to state and regulatory quality compliance, HEDIS and Stars performance, and quality improvement initiatives.
Supervises a team of QI Coordinators and QI Care Gap Coordinators focused on quality improvement tasks aimed at achieving successful outcomes and benefit maximization towards members care.
Oversees processes and procedures to ensure compliance with contractual, regulatory (Federal/State) and annual quality metric reporting.
Monitors and tracks production and quality driven work/outcomes on assigned team. Monitors associates' performance, productivity and quality through standard reports.
Assigns and distributes workload, monitors productivity and quality levels.
Conducts one-on-one coaching and provides associates feedback routinely and as needed. Provides counseling/corrective action procedures when required.
Provides significant input and delivery of associates' performance evaluations and hiring/terminations.
Conducts training for new associates and re-training based on changing policy and procedure.
Prepares and completes projects, reports and assignments as needed to meet departmental goals and initiatives.
Assists in the implementation of and maintains a standardized quality management plan and program to ensure compliance with external regulatory and accreditation requirements.
Assist in researching and developing performance measurement and outcome studies to assess and improve the health status of the membership. Assist in planning, organizing and managing the design, development and analysis of a wide variety of topics relevant to health care services.
Maintains a knowledge base of HEDIS requirements and implementing clinical performance methods to improve HEDIS performance.
Attends department and/or quality improvement related meetings in the absence of manager.
Makes process improvement recommendations to senior leadership.
Acts as primary contact for escalated calls or issues or that require additional research and/or special handling, and investigates issues of an unusual nature and proposes solutions in a clear and concise manner.
Additional duties as assigned.
Required A Bachelor's Degree in a related field HealthCare, Nursing, Public Health, Health Administration (preferred)
Required or equivalent work experience
Required 3 years of experience in directly related Quality Improvement job duties
Required 4 years of experience in a managed care environment
Required 1 year experience in leading/supervising others
Preferred Other Medicare / Medicaid experience
Intermediate Other Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards
Intermediate Knowledge of community, state and federal laws and resources
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Intermediate Demonstrated analytical skills
Intermediate Demonstrated problem solving skills
Advanced Ability to work in a fast paced environment with changing priorities
Intermediate Ability to multi-task
Advanced Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to effectively present information and respond to questions from peers and management
Intermediate Ability to influence internal and external constituents
Intermediate Ability to lead/manage others
Licenses and Certifications: A license in one of the following is required:
Preferred Licensed Practical Nurse (LPN)
Preferred Licensed Specialist Clinical Social Worker (LSCSW)
Preferred Certified Professional in Healthcare Quality (CPHQ)
Required Intermediate Microsoft Word
Required Intermediate Microsoft Outlook
Required Intermediate Healthcare Management Systems (Generic)