Responsible for the day to day activities of the quality management department that provide quality improvement, denials, and appeals functions for IPAs. Performs quality improvement activities for assigned IPAs.
- Coordinates coverage of local staffing needs, arranging coverage for sick calls and vacation planning and monitors timecard accuracy.
- Provides direct day to day oversight for all assigned staff.
- Delegates tasks to appropriate staff within the QI department
- Responsible to oversee the completion of the QI quarterly program evaluations, monitoring improvement and compliance.
- Performs direct QI functions for local IPA, as assigned.
- In conjunction with the local Medical Director, Executive Director, and QI Director, implements quality improvement strategies.
- Day to day responsibility for the QI Programs (P4P, 5 STAR, etc.)
- Communicates changes in policy and procedure to assigned staff.
- Participates in the interview and counseling process with assigned staff.
- Meets regularly with assigned staff to ensure performance and monitor productivity.
- Reports performance to targets and works with QI Director to develop intervention strategies.
- Provides lead communication link from denial and appeal unit to the UM department.
- Associate/Bachelors Degree or equivalent years of experience in a Managed Care organization or a related field.
- RN/LVN with current California License
- Experienced in Denials, Appeals, and Grievance resolution
- Experience in the development and implementation of improvement strategies (both clinical and service)
- Self motivated with strong quantitative and organizational skills.
- Ability to look at challenges as opportunities.
- Knowledge of general PMG/IPA operations a plus.
- Flexible and adaptable of schedule to attend various meetings and/or promotional events.
- Previous experience developing departmental infrastructure
- Strong quantitative organizational and administrative skills
- Ability to manipulate large databases and to produce meaningful analytical and management reports
- Ability to perform complex problem solving
- Ability to work effectively with physicians
- Knowledge of HMO and MCO operations, and continuous quality and utilization/medical management techniques and operations
- Strong people and project management skills
- Previous external accreditation experience (NCQA, JCAHO) preferred
- Proficient in Microsoft Office products.
NAMM North America Medical Management - 12 months ago