Corporate Quality Manager

Job Details

Job Location
Corporate Headquarters - Chula Vista, CA

Position Type
Full Time

Education Level
Graduate Degree

Salary Range
$130,639.58 - $160,033.48 Salary

Job Category
Management

Description

POSITION SUMMARY

Under the direction of the Director of Corporate Quality, manages the day-to-day operations of the Corporate Quality Department including the areas of grievances and appeals (G&A), the identification, resolution, and tracking of potential quality issues (PQIs), facility and medical record reviews, Health Effectiveness Data and Information Set (HEDIS) file review and clinical oversight, and the quality reporting. Serving in a clinical and operational role, supports the provision and access to quality health care and member advocacy.

RESPONSIBILITIES

• Upholds Community Health Group's (CHG's) quality improvement and health equity program according to standards and requirements promulgated by the Department of Managed Health Care (DMHC), the Department of Health Care Services (DHCS), the National Committee for Quality Assurance (NCQA), the Centers for Medicare and Medicaid (CMS), and based on evidence-based standards of practice.
• Supervises the Corporate Quality Nurses, the Grievances and Appeals Supervisor, and the Corporate Quality Specialist in the performance of their role and position description.
• Oversees and provides guidance and assistance to the clinical and non-clinical staff to meet individual and departmental performance goals, metrics, and regulatory requirements.
• Maintains and develops departmental policies, procedures, desk references, job aids, and guidelines under the direction of the Corporate Quality Director.
• Develops, produces, validates, and submits regulatory and management reports directly or in collaboration with staff.
• Oversees CHG's facility and medical record review process in accordance with DHCS along with CHG's DHCS-certified Master Trainers.
• Oversees CHG's grievance and appeal process in accordance with regulatory and accreditation standards and advocates on behalf of members and to appropriately identify and address potential quality issues in accordance to established policies, procedures, and standards.
• Oversees the complete and timely investigation and resolution of potential quality issues and the implementation and follow-up of corrective action when indicated.
• Provides analytical support to clinical programs; performs clinical assessments and clinical audits and file review as necessary to support the Corporate Quality Department responsibilities including HEDIS-related activities.
• Assists the Director of Corporate Quality in producing internal and/or external management and regulatory reports.
• Trains staff and providers
• Ensures company compliance with regulatory guidelines by participating in the preparation process required for regulatory and accreditation audits; assisting with the implementation of corrective action plans.
• Is able to do the work of direct reports if necessary due to absences or during spikes in volume.
• Responsible for the operations of the department in the absence of the director.

And all other duties assigned by the department director.

Qualifications

EDUCATION

• Current, unrestricted RN license in California

• MSN or equivalent.

EXPERIENCE/ SKILLS

• 5 years of professional work experience in healthcare
• 2 or more years or equivalent in supervision

• Quality management experience preferred
• Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum

• Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas and the ability to present confidently in group settings.
• Organizational skills with the ability to handle multiple tasks and/or projects at one time
• Customer service skills with the ability to interact professionally and effectively with providers, physicians, and staff from all departments within and outside the Company
• Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization
• Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements
• Problem solving skills with the ability to look for root causes and implementable, workable solutions
• Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs
• Track record of producing work that is highly accurate and demonstrates attention to detail.
• This position requires occasional travel within the San Diego County area.

PHYSICAL REQUIREMENTS

• Prolonged sitting
• Occasional travel within the county if San Diego
• Must be able to lift and/or move up to 10 pounds and have close vision
• May be required to work evenings and weekends

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and training. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.