Sup, Clinical Quality Mgmt

About the role

The position is responsible for supervising Clinical Quality Management (CQM) staff production and quality processes; assisting in the development of policies and procedures related to CQM; meeting CQM contractual requirements; and ensuring compliance with URAC standards.

Responsibilities

• Hires, coaches, counsels, evaluates, and develops clinical and non-clinical staff.
• Supports recruitment efforts by interviewing, selecting, and training new staff.
• Ensures that new staff are fully onboarded and trained.
• Conducts regular 1:1 and team meetings to ensure alignment to work requirements, timely communication and performance management.
• Supervises individual staff caseload and beneficiary needs to ensure timely delivery of care as well as productivity and timeliness requirements.
• Assigns cases appropriately according to clinicians' scope of practice.
• Maintains a consistent PQI caseload of 2 - 5 cases.
• Requests query reports, as appropriate, and analyze data supporting focused reviews and quality studies.
• Facilitates working case review meetings.
• Conducts Potential Quality Issue (PQI) investigations by performing a timely and complete case analysis.
• Ensures adherence to accreditation standards, TRICARE policy, contractual requirements and nationally recognized practice standards.
• Participates on TriWest committees as a representative of Clinical Quality Management.
• Performs other duties as assigned.

Requirements

• RN or LCSW (Independently Licensed Clinical Social Worker) with current unrestricted license in appropriate state or territory of the United States
• If supporting TRICARE contract, must be a U.S. Citizen
• If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 5+ years of clinical experience in a variety of settings (behavioral health and medical/surgical)
• 2+ years of supervisory experience
• 1+ year of experience in Quality Management to include conducting medical records abstracting and quality investigations

Qualifications

• Bachelor's degree in Nursing Health Administration, health-related field or equivalent and experience
• Certified Professional in Healthcare Quality (CPHQ)
• General knowledge of nationally recognized standards of care, Interqual, CMS, HEDIS, AHRQ, TRICARE, or government health care programs
• General knowledge of Medicare, TRICARE, or government health care programs

Skills

• Coaching / Training / Mentoring
• Communication / People Skills
• Computer Literacy
• Coping / Flexibility
• Delegation Skills
• Organizational Skills
• Problem Solving / Analysis
• Team-Building / Team Player
• Technical Skills

Benefits

We offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

Salary range: Around $100,000 to $111,000 per year.

Equal Employment Opportunity: TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply.