The Quality Management Manager worlks collaboratively with Quality Management Director to coordinate the development, implementation, monitoring and evaluation of the organization’s overall quality management program.  Collaborate with internal and external customers to identify trends and opportunities for individual and systemic improvement, prioritize and implement agreed upon improvements.  Ensure compliance with state, federal and health plan regulations, standards, applicable laws, statutes and rules. Provide expertise, technical assistance, consultation and training to staff and practitioners regarding regulations and standards.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.  Other duties may be assigned.

1.        Effectively manage an experienced and professional Quality Management staff.

2.        Promote QM staff development and assist the staff in meeting personal, departmental and organizational goals.

3.        Develop, implement and monitor organization’s Quality Management Annual Program Description, Work Plan, and QM Program Evaluations.

4.        Work in collaboration with Quality Management Committee Facilitator and Chair to plan, prepare and organize the monthly agenda, responsible for overseeing meeting preparation.

5.        Follow-up on all committee activities to ensure completion.

6.        Work in collaboration with the Credentialing Department, the Quality Medical Director and Quality Director to plan, prepare and organize the Credentialing and Peer Review Committee agenda monthly

7.        Provide oversight for both the member appeals and grievance resolution processes including tracking, trending and identifying opportunities for improvement.

8.        Ensure compliance with state, federal and health plan standards for managing appeals and grievances.

9.        Oversee the development, analysis and reporting of Grievance and Appeal data for various committees

10.     Use and/or oversee the use of data analysis and process improvement tools to monitor and improve performance.

11.     Develop, implement and monitor QM policies and procedures in accordance with health plans, DMHC and NCQA requirements.

12.     Work collaboratively with the entire organization to be in a state of continual readiness in regards to Delegation Oversight Audits performed by Health Plans which have delegated Monarch for various functions.

13.     Maintain responsibility for audit coordination.

14.     Oversee Provider Office audits including Medical Record Documentation, Patient Access, Initial Site Visit Reviews, HEDIS and Delegation Oversight of any third party delegates.

15.     Demonstrate initiative, effectively make decisions and exhibit sound professional judgment.

16.     Other Managerial responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising employee performance; rewarding and disciplining employees; addressing complaints and resolving problems.

17.     Regular and consistent attendance.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:  Graduate of an accredited nursing school or Bachelor''s degree in a health care related field from a four year college or university, (MHP or MHA preferred); 6-8 years related experience in health care, 4-5 years managerial/supervisory experience; or equivalent combination of education and experience.  Minimum of two years of Management and Quality Management experience in a managed care setting.  Strong working knowledge of NCQA, DMHC, CMS and state MediCal regulatory requirements.  Experience in applying quality improvement philosophy and process as related to health care.  Excellent analytical and problem solving skills, ability to work collaboratively with physicians and all levels of staff within the organization.

LANGUAGE SKILLS:  Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.  Ability to respond to common inquires or complaints from customers, regulatory agencies, or members of the business community.  Ability to write speeches and articles from publications conforming to prescribed style and format.  Ability to effectively present information to management, public groups, or boards of directors.

MATHEMATICAL SKILLS:  Ability to work with mathematical concepts such as probability and statistical inference.  Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

REASONING ABILITY:  Ability to define problems, collect data, establish facts, and draw valid conclusions.  Ability to interpret an extensive variety of technical instructions in mathematical or diagram form. Deal with several abstract and concrete variables.

LICENSES, CERTIFICATES, REGISTRATIONS:  Active, non-restricted California RN License preferred, but non-clinical health care professionals with quality and management experience considered. 

OTHER SKILLS and ABILITIES:  Excellent verbal and written communication skills. Excellent Customer Service skills. Self-motivated with effective critical thinking skills.  Ability to work collaboratively as part of the clinical team.  Thorough knowledge of managed care, third party payers, regulatory requirements, and government entitlement programs.  Ability to multi-task, set priorities and make decisions. Ability to work independently. Proficient with Microsoft Office, including Outlook, Word, Excel and PowerPoint. 

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

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