RN Manager of Quality Improvement - Health Plan

Location: Honolulu, HI
Date Posted: 02-01-2018
RN Manager of Quality Improvement - Managed Care
Kapolei, HI (Near Honolulu) 
Your Job Summary: 
The Manager of Quality Improvement is responsible for developing, coordinating, and implementing quality initiatives within the organization.  The QI Manager provides clinical and operational expertise while supervising a team responsible for monitoring and evaluating the quality of care/service, appropriateness, continuous improvement, member satisfaction, and results of actions across the continuum of care to members.  The Manager assists in coordinating the quality management program activities throughout the functional areas of the health plan network and delegated provider entities.  They are responsible for maintaining compliance with federal and state regulations and internal standards; facilitating assigned quality committees; and collecting, analyzing, and reporting data. The primary focus of this position is providing direction and improving programs related to NCQA, HEDIS®, and CAHPS
Your Benefits: 

Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health. 

Your Background:
Valid, unrestricted state Registered Nurse (R.N.) license.
Bachelors degree in healthcare related field preferred; Master’s degree a plus.
Certified Professional in Healthcare Quality (CPHQ) is highly preferred.
Roughly 1-3 years acute care clinical nursing experience.
Around 2-3 years’ experience in a Managed Care Organization (Health Plan/HMO/MSO/TPA/IPA/etc).
Minimum of 5-7 years Quality Improvement or Utilization Review experience (mix of both preferred).
Around 2-4 years of progressive staff supervision or management experience within a managed care or hospital environment.
Strong working knowledge of Quality Improvement initiatives in a Managed Care environment is required.
Extensive knowledge of Medicare, Medicaid and similar state health programs, their regulatory guidelines, benefit management and coverage determination, reconsideration, and appeal processes.
Requires direct working experience with Quality Improvement Initiatives such as: HEDIS/NCQA/CAHPS
Previous external accreditation experience (NCQA, URAC, JCAHO, etc) preferred.
Ability to analyze and integrate information and make sound decisions based upon established guidelines.
Resourcefulness as demonstrated by the effective application of professional knowledge to new situations.
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
Experience in training, teaching, and coaching staffs to meet operational requirements and goals.
Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.

Your Duties:
Assists in establishing quality improvement objectives; develops and implements the comprehensive Quality Management Program to meet the demographic and epidemiological needs of the population served.  The primary focus of this position is providing direction and improving programs related to STARS, HEDIS, and CAHPS.  Ensures compliance with federal, state, and accreditation standards by developing, implementing and maintaining compliance processes within the department.  Supervises delegation oversight activities including a review of medical record audits and policies and procedures to determine compliance with established standard.  Ensures compliance standards are met by performing facility site review, delegation and credentialing oversight and auditing, reporting results and recommendations to committee and providing support and education to provider organizations.   Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.  Promotes understanding, communication, and coordination of the quality management program.
Maintains highly effective staff by selecting, developing, and training employees; communicating job expectations and monitoring job results; counseling and coaching employees; and by initiating, coordinating, and enforcing systems, policies, and procedures.  Leads and supports a culture of engaged performance within the team in order to drive the achievement of common goals.   Recognizes and utilizes appropriate channels for communication and encourages two-way communication and encourages staff to participate in creative program development.  Work collaboratively with key health care professionals toward identification of opportunities for improvement, trend analysis, education and development of appropriate action plans for problem resolution.
Assists in developing the annual operating and capital budgets to sufficiently meet departmental needs and ensures that department stays within budget and accounts for variances.  Represents QM department by participating in assigned quality committees and interdisciplinary workgroups.  Serves as quality resource for internal and external customers including Medical Directors and provider organizations.  Resolves quality issues by identifying the problem, examining solution options, implementing an action plan and providing resources.

® “HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).”
CareNational Healthcare Services
480.478.1635 (CALL – TEXT – FAX)

Sign-Up for Job Alerts
this job portal is powered by CATS