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Oversees the day to day operations for patient care advocate field staff and for the overall coordination and supervision of activities as it relates to state and regulatory quality compliance, HEDIS and quality improvement initiatives. Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through onsite and face-to-face interaction with members and providers at large IPA and/or group practices.
Supervises patient care advocate field staff to achieve successful quality outcomes and benefit maximization towards members care.
Supervises processes and procedures to ensure compliance with contractual, regulatory (Federal/State) and annual quality metric reporting.
Provides leadership and support to front-line staff.
Monitors and tracks production and quality driven work/outcomes on assigned staff. Monitors associates' performance, productivity and quality through standard reports.
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.
Manages the E-time process, including training and education.
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 company meetings in absence of manager.
Makes process improvement recommendations to management.
Act as primary contact for escalated calls or issues or that require additional research and/or special handling.
Investigates issues of an unusual nature and proposes solutions in a clear and concise manner.
Establishes and maintains relationship with Providers and hospitals.
Performs other duties as assigned.
Required A Bachelor's Degree in HealthCare, Nursing, Public Health, Health Administration or directly related degree
Required or equivalent work experience
Required 4 years of experience in directly related Quality Improvement job duties
Preferred 1 year of experience in managed care
Preferred 1 year experience in leading/supervising others
Preferred Other Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards
Required Other Experience with Medicaid/Medicare
Intermediate Knowledge of community, state and federal laws and resources
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated analytical skills
Advanced Demonstrated problem solving skills
Advanced Ability to work in a fast paced environment with changing priorities
Advanced 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 Clinical Social Worker (LCSW)
Preferred Cerified Professionals in Healthcare Quality (CPHQ)
Required Beginner Microsoft Excel
Required Intermediate Microsoft Word
Required Beginner Microsoft Visio
Required Beginner Microsoft PowerPoint
Required Intermediate Microsoft Outlook
Required Intermediate Healthcare Management Systems (Generic)