Quality Improvement Clinical Manager / Job Req 1023712205

Hybrid: Applicants must be a California resident as of their first day of employment.

Responsibilities

• Oversee operational and tactical strategies for clinical safety activities to promote detection, prevention, and remediation.
• Lead cross-functional meetings to address system trends based on monitoring issues, findings, or analysis of clinical safety activities and other data points.
• Develop and implement process improvements or workflows relating to Facility Site Review (FSR), Potential Quality Issues (PQI), Provider Preventable Conditions (PPC), Grievance & Appeals (G&A), or other related clinical quality activities that improve efficiency or effectiveness.
• Collaborate with other departments (i.e., Provider Services, Compliance, etc.) for cases requiring escalation and/or address barriers to ensure timely closure of corrective action plans.
• Manage the Skilled Nursing Facility/Long Term Care (LTC) quality monitoring program in collaboration with the LTC to ensure safe care for members.
• Manage ad hoc chart reviews to assess, address, or monitor quality of care issues, trends, regulatory audit findings, or strategic priorities.
• Contribute toward clinical key performance indicators at Joint Operating Meetings.
• Conduct cross-functional root cause analysis and action plans to address quality of care issues.
• Develop inter-rater reliability and quality assurance processes to ensure accuracy, appropriateness, and competency to process PQIs and Grievance and Appeals cases.
• Develop, update, and maintain policies and procedures, standard operating procedures, and other operational documents pertaining to the clinical safety unit.
• Contribute to the Quality Improvement Health Equity (QIHE) Program trilogy documents (evaluation, program description, and workplans) and related documentation.
• Facilitate clinical quality oversight through periodic reviews, chart audits, and reporting of key performance indicators.
• Address complex quality of care problems and facilitate an integrated approach to improvement initiatives.
• Develop a comprehensive approach to achieving internal and external standards for quality and clinical safety.
• Develop and maintain dashboards for providers with defined expected outcomes & benchmarks based on clinical quality.
• Provide contributions and clinical expertise relating to quality measures (i.e., HEDIS), Performance Improvement Projects (PIPs), and Quality Improvement Projects (QIPs), and other strategic initiatives.
• Provide in-person and/or virtual training on clinical processes to support clinical safety initiatives.
• Manage staff to ensure adherence to policy and procedures, standard operating procedures, and regulatory requirements.
• Perform data collection, measurement, maintenance, and analysis.
• Develop reports and presentations to support regulatory submissions.
• Coordinate and consult with Alliance departments on clinical quality improvement activities.
• Keep abreast of healthcare industry best practices and managed care regulatory requirements.
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
• Train, supervise, and audit staff performance.
• Perform other duties and special projects as assigned.

Requirements

• California licensed Registered Nurse.
• Bachelor’s degree in health-related field preferred; BSN is strongly preferred.
• A Master’s degree may substitute for two years of the required experience, or an equivalent combination of education and experience which would provide the required knowledge, skills, and abilities may be qualifying.
• 4 years of experience in a managed care organization.
• Experience in FSR, PQI, G&A, quality management, patient safety, or care coordination strongly preferred.
• Previous experience in a leadership role required.

Skills

• Ability to work collaboratively with physicians, staff, and external organizations to improve quality outcomes.
• Strong communication and presentation skills; training/meeting facilitation skills a plus.
• Solid relationship building and interpersonal skills.
• Excellent writing, research, analytical, and time management skills.
• Excellent coordination skills, including multi-tasking and setting priorities on work assignments.
• Ability to organize and coordinate various activities involved in a research, collaborative, and demonstration project.
• Knowledge of managed care organization practices, policy, programs, initiatives, and functions.
• High degree of independence, flexibility, initiative, and commitment.
• Ability to work effectively with diverse populations, both internally and externally.
• Solid critical thinking and problem-solving skills.
• Ability to utilize sound judgment and promptly report potential risks.
• Ability to work in a fast-paced, patient-service oriented environment.
• Demonstrated ability to promote quality improvement through development and maintenance of standards.
• Ability to handle PHI and maintain confidentiality at all levels.
• Proficiency in Windows including Microsoft Office suite (Word, Excel, PowerPoint).

Physical Requirements

• Constant and close visual work at desk or on a computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Frequent use of telephone headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and various other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional driving of automobiles.

Pay

$167,440.00 - $251,160.00 annually

Additional Information

• Number of Employees Supervised: 7-10
• Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process.