The Quality Improvement Manager is responsible for internal oversight of clinical management programs for medical and/or mental/behavioral health services. This includes overseeing PQI procedures, overseeing production and updating of various QI documents, monitoring and taking action to improve key indicators of quality such as HEDIS rates (or similar measures), accessibility and availability, coordination of care, etc.
Essential Duties & Responsibilities
- Oversee resolution process for quality of care complaints and potential quality issues.
- Oversee essential QI documents such as QI Policy & Procedures, QI Work Plan and QI Program description.
- Develop process improvement knowledge among staff and create culture of quality.
- Ensure that quarterly reports of key quality indicators are developed and presented to the QIC.
- May respond to health plan NCQA requirements or similar requirements.
- Oversees/analyzes initiatives and interventions using HEDIS metrics.
- Makes recommendations to improve organization's performance on quality issues including but not limited to compliance, member and provider satisfaction, safety, access, availability, and coordination of care.
- Other duties as assigned.
BSN/MSN or MSW or MPH (biostatistics or epidemiology a plus) preferred
Current licensure as Registered Nurse, certification in Quality Management and Case Management preferred orLCSW or MFT preferred. Fully licensed to practice in this State at the highest level as a Clinical Social Worker to practice independently without restrictions or supervision.Some positions may require CPHQ certification
Government Clearance & US Citizenship Requirement
Two years management experience in a clinical or behavioral health care environmentOne year managed care experience preferably in Quality Improvement, CM, QM and/or UMOne year experience managing databases and conducting analysis and reportingORAny combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Knowledge, Skills & Abilities
- Ability to complete statistical analysis and reporting
- Strong working knowledge of PC programs such as Business Objects, Microsoft Excel, Access, and Word
- Experience working with large data sets. Requires understanding of health care data (claims, pharmacy, authorizations, and membership) and issues; medical terminology; and managed care
- Knowledge of NCQA and HEDIS guidelines, DHS, DMHC and CMS regulations
- Demonstrated effective oral and written communication skills
- The following section describes the general physical requirements for this position. Please note that constant refers to more than 81% of time; significant refers to 40-80%; and moderate refers to 20-40% of the time.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication.
- Required to have speaking ability to express or exchange ideas.
- Constant computer usage including constant typing and/or eye strain.
- Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
- Constant phone usage; headsets may be required.
- Significant travel may be required between work sites and/or out of area.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Constant interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
- Constant thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one or several things to the next.
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.
Health Net, Inc. supports a drug-free work environment and requires
pre-employment background and drug screening.
Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action
Employer - Minorities/Females/Veterans/Disability