Assistant manager quality management job description

Primary Job Function: Medical Management

ID**: 24791

**Job Brief**

Remote Healthcare Quality Manager with Medicaid & Medicare experience needed for growing MCO. You can live in the Eastern or Central Time Zone.

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .

**Responsibilities:**

Under the direction of the Director, Quality Management, the Manager of Quality Management is responsible for providing oversight, direct supervision and day-to-day management of the Quality Management Team. This position oversees integration of quality monitoring and interventions for improving HEDIS rates and provides process assistance to business owners for performance improvement projects. The incumbent provides direction and support to the Quality Management team and assists the Director in ensuring Plan compliance with state regulations and accreditation standards.

+ Directs the Quality Operations Program, following CMS Stars Quality Standards, as well as, the contract with the State and requirements of regulatory bodies

+ Maintains current knowledge of Health Plan Policy and Procedures, State Requirements, CMS Standards and HEDIS specifications.

+ Participates in the planning, developing, and implementing Health Plan activities related to the HEDIS process, improving HEDIS rates and member satisfaction.

+ Ensures the Quality Management Team complies with all applicable statutory provisions, contracts, and established policies and administrative procedures.

+ Participates and assists in the development of all necessary protocols, policies and procedures, operational strategies and plans to develop and implement Quality Management programs.

+ Ensures complete, accurate and timely reporting to regulatory bodies.

+ Supports the development and implementation of quality management programs and pilot programs designed to improve HEDIS rates and/or member satisfaction.

+ Identifies barriers to project and program success and works toward resolution by informing the accountable functional area and presenting plans to resolve the issue when possible.

**Education/Experience:**

+ Bachelor's Degree or equivalent education and experience in health related field preferred.

+ RN with a Clear/Active license in any US State preferred.

+ 3-5 years Management experience in Medicare/Medicaid Quality Improvement.

+ Previous experience in managed care required.

+ Experience in manageing a team in a remote work setting preferred.

EOE Minorities/Females/Protected Veterans/Disabled

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

Under the direction of the Director, Quality Management, the Manager of Quality Management is responsible for providing oversight, direct supervision and day-to-day management of the Quality Management Team. This position oversees integration of quality monitoring and interventions for improving HEDIS rates and provides process assistance to business owners for performance improvement projects. The incumbent provides direction and support to the Quality Management team and assists the Director in ensuring Plan compliance with state regulations and accreditation standards.

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• Directs the Quality Operations Program, following CMS Stars Quality Standards, as well as, the contract with the State and requirements of regulatory bodies
• 
  
• Maintains current knowledge of Health Plan Policy and Procedures, State Requirements, CMS Standards and HEDIS specifications.
• 
  
• Participates in the planning, developing, and implementing Health Plan activities related to the HEDIS process, improving HEDIS rates and member satisfaction.
• 
  
• Ensures the Quality Management Team complies with all applicable statutory provisions, contracts, and established policies and administrative procedures.
• 
  
• Participates and assists in the development of all necessary protocols, policies and procedures, operational strategies and plans to develop and implement Quality Management programs.
• 
  
• Ensures complete, accurate and timely reporting to regulatory bodies.
• 
  
• Supports the development and implementation of quality management programs and pilot programs designed to improve HEDIS rates and/or member satisfaction.
• 
  
• Identifies barriers to project and program success and works toward resolution by informing the accountable functional area and presenting plans to resolve the issue when possible.
  
  
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Education/Experience:

• 
  
• Bachelor’s Degree or equivalent education and experience in health related field preferred.
• 
  
• RN with a Clear/Active license in any US State preferred.
• 
  
• 3-5 years Management experience in Medicare/Medicaid Quality Improvement.
• 
  
• Previous experience in managed care required.
• 
  
• Experience in manageing a team in a remote work setting preferred.
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Apply Now

Molina's Quality Management function implements, oversees, and maintains new and existing healthcare quality monitoring activities and programs; ensures quality monitoring audits and investigations are performed in accordance with prescribed quality standards; informs data collection, reporting, and analysis to monitor key quality management activity; and provides direction and implementation of federal/state quality management compliance activities.

The Manager, Quality Management assists Health Plan Quality Leadership with providing the strategic direction and implementation of Health Plan quality management activities.

• Ensures individual and systemic quality of care investigations are performed timely, accurately, and in accordance with state-based requirements.

• Maintains structure and processes for tracking and trending reportable incidents, quality of care events, member service concerns, and mortalities.

• Leads and oversees quality monitoring activities, including audits of medical record quality, services and service sites, health and safety, and follow-up of monitoring of placement settings.

• Prepares written documentation and business practices (e.g., policies and procedures, desk-level procedures, manuals, and process flows) that explain the business requirements and how the unit operationalizes those requirements.

• Leads and safeguards the creation and ongoing revision of policies and procedures reflective of state requirements for all quality management functions, including quality monitoring audits, credentialing and recredentialing, quality of care concerns, and peer review.

• Manages training and education of quality management staff about their role, the business, and the compliance rules/requirements that govern the unit, including new hire orientation, annual role-based and function-based trainings, and employee communications.

• Ensures all quality management unit staff are well-versed in the requirements of the quality management program and day-to-day work processes to support compliance with state contract, policies, and program requirements.

• Implements and performs tracking and trending of quality management unit compliance requirements on an ongoing basis, including operational key performance indicators, process reviews, and gap analyses.

• Utilizes proven quality improvement methods, such as the Plan-Do-Study-Act (PDSA) cycle, to facilitate individual, team, and organizational process improvement.
Job Qualifications

Required Education

• Bachelor's Degree or equivalent combination of education and work experience.

Required Experience/Knowledge, Skills & Abilities

• 5+ years experience in managed healthcare, including at least 2 years in health plan quality management and clinical quality investigations.

• Supervisory experience.

• Experience providing coaching and/or direction to others.

• Strong strategic thinking skills.

• Strong communication skills, both verbally and written.

• Ability to interact effectively with business owners, senior management, and peers across the organization.

• Proficient in Microsoft Office tools (Outlook, Excel, Visio, etc.)

Required License, Certification, Association

• Arizona-licensed RN, physician, or physician's assistant in good standing.

Preferred Education

• Master's degree in related discipline or equivalent work experience.

Preferred Experience

• Project management and team building experience.

• Demonstrated experience in leading significant cross-functional work.

• Provider credentialing and subcontractor monitoring experience.

Preferred License, Certification, Association

• Certified Professional in Healthcare Quality (CPHQ) by the National Association of Healthcare Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.