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Quality / HEDIS Manager

Company: Arizona Priority Care
Location: Chandler
Posted on: April 8, 2021

Job Description:

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 action.
  • Responsible for monitoring and evaluation of staff performance.
  • 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 services/operations.
  • 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 provider/staff education.
  • Generates professional letters to health plan (appropriate content, free of grammatical errors), summarizing AZPC findings and actions.
  • 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 and coordination.
  • 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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