Quality / HEDIS Manager
Company: Arizona Priority Care
Posted on: April 8, 2021
The--Quality /HEDIS Manager--has direct oversight and reporting
responsibilities for Quality and processes. Plans, develops, and
directs all QI functions per the QI Program and Work Plan while
championing the department by routinely identifying quality
improvement opportunities throughout AZPC.This includes
communication and monitoring of initiatives as well as promoting
culture changes that support an environment of quality.Provides
leadership necessary to achieve national best practice performance
levels in quality improvement while implementing evidence based
practices. Maintains current knowledge of CMS and NCQA standards
and has working knowledge of HEDIS, and CMS 5 Star measures and
data collection. Must maintain current knowledge of State, Federal,
Health Plan regulatory requirements, and Arizona Priority Care
policies and programs. The QI Manager is also a member of the
Transplant Team, when delegated. REQUIREMENTS:
- Annual and ad hoc review of corporate Quality and Compliance
Programs, as well as the corporate P&P's, and modify as
appropriate to accurately reflect AZPC operations.
- Oversight of Appeals & Grievances process, ensuring cases are
handled appropriately, according to health plan and regulatory
requirements, and within specified timeframes.
- Oversight of Potential Quality Issue (PQI) process including
initial clinical review and investigation, root cause analysis,
appropriate recommendations for solutions, and presentation to the
Medical Director for severity leveling and action plan. Serve as a
liaison with departments for investigation, collaboration and
resolution of all PQI's.
- Oversight of the QI clinical and nonclinical staff, providing
training, support/direction for issues requiring evaluation, root
cause analysis and intervention, and requests for corrective
- Responsible for monitoring and evaluation of staff
- Ensure departmental statistics are maintained, analyzed,
trended and reported accurately.
- Develops and implements standard operating procedures (SOP's)
for identification, collection, and analysis of performance
measurement data to continually improve department
- Responsible for completing all QI Program activities for
presentation to QIC/UMC including summaries, QIP's, policies,
programs, and work plan.
- Responsible for scheduling work activities to meet QI goals,
deadlines, and timely submission of quarterly/semi-annual quality
reports and work plans to QIC/UMC, health plan, and corporate
office, as appropriate.
- Serve as a liaison with departments for investigation,
collaboration, and resolution of all identified internal quality of
care issues, as well as acting as a liaison with contracted
practitioners and providers regarding QI issues and ongoing
- Generates professional letters to health plan (appropriate
content, free of grammatical errors), summarizing AZPC findings and
- Serves as a liaison with regulatory agencies for reporting
requirements and ensures ongoing compliance is met with regulatory
and accreditation agencies including, but not limited to, CMS,
NCQA, and contracted health plans.
- Understands appropriate use of Quality audit tools.
- Responsible for ensuring accuracy with current reports and
making recommendations for improvements.
- Will ensure accurate and timely coordination and completion of
on-site medical record review and site audits, as delegated.
- Participates in annual health plan QI and UM audit preparation
- Participates in the implementation and provision of Quality
reporting for the Direct Contracting Entity, (DCE).
- A member of the DCE committee.
- Establishes effective professional relationships to facilitate
quality processes internally and externally.
- Strong teamwork philosophy and willingness to accept change
proactively. EXPERIENCE: Three to Five years previous experience
directly related to QI. Experience with NCQA accreditation process.
Previous experience in an acute / managed care setting related to
QI job responsibilities. Excellent written and oral communication
skills. Current and unrestricted AZ Driver's License and proof of
insurance required. Advanced leadership supervisory skills.
Exceptional organizational and project management with finite
attention to details. EDUCATION: Current, unrestricted AZ RN
license. Bachelor's degree in nursing or other health care field
required - Master's degree preferred - CPHQ highly preferred Part
of Arizona Priority Care's hiring process includes a background
check and drug screen.
Keywords: Arizona Priority Care, Chandler , Quality / HEDIS Manager, Executive , Chandler, Arizona
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