Manager, Market Quality Improvement - Must Reside in Georgia

Job Summary:

The Manager, Market Quality Improvement manages the day-to-day prioritization of staff activities in collaboration with Director, Quality Improvement. The Manager will be responsible for developing quality documents in compliance with state and federal requirements and work with departments outside of quality to obtain information for reports.

Essential Functions:

• Responsible for Corporate oversight of the HEDIS Medical Record Review Unit as needed for the assigned market
• Responsible for development and oversight of Quality Improvement (QI) Projects and Performance Improvement Projects related to HEDIS and pay for performance (P4P) requirements
• Ensures compliance with External Quality Review audits/studies, Performance Improvement Projects, and Quality Improvement Projects required by the state, NCQA, and other accreditation bodies
• Responsible for the review of QI issues regarding compliance with Federal, State, and Accreditation requirements
• Ensure all policies and procedures are aligned with Federal, State, and Accreditation requirements
• Responsible for the annual review, program description, program plan, and update of QI Department policies and procedures
• Provide education to internal and external customers on quality improvement functions
• Respond to questions that pertain to HEDIS and Quality Improvement from providers and internal staff members
• Foster relationships with all internal departments and represents CareSource to community-based and state programs
• Collaborate with business owners to establish, implement, and develop best practices for P4P quality directives
• Implement opportunities for process improvement that impact quality measurements in assigned market
• Monitor industry trends as it relates to healthcare and identify areas of opportunity for improvement
• Responsible for ensuring business owners successfully complete all deliverables related to performance improvement plans (PIPs) and quality improvement plans (QIPs) within defined timeframes
• Conducts analysis, including root cause analyses with support from identified business units and ensure data is presented and used efficiently to meet the quality goals
• Follows enterprise standards and procedures for all quality reporting and documentation and communicate areas of strengths as well as needs to the Quality Improvement  Committee
• Perform all facets of quality management to include the development of detail work plans, setting deadlines, assigning responsibilities and monitoring/summarizing project progress
• Establish, monitor and review mechanisms to assess and document each business units level of compliance with each measure and coordinate corrective actions
• Attends and participates in market quality committees
• Guide and direct successful completion of daily tasks and projects
• Interview, select and train new team members
• Conduct performance management activities for direct reports, to include monthly one-on-one meetings, annual performance appraisals, and discipline as appropriate
• Perform any other job related instructions, as requested

Education and Experience:

• Bachelor’s Degree or equivalent years of relevant work experience is required
• Completion of an accredited Registered Nursing degree program or Bachelor’s of Science in Nursing (BSN) is preferred
• Master’s Degree in Nursing (MSN), Public Health, or healthcare related field is preferred
• A minimum of three (3) years of experience in a healthcare or managed care organization is required
• Previous management experience is required
• Medicaid and/or Medicare experience preferred
• Experience in quality metrics preferred

Competencies, Knowledge and Skills:

• Intermediate proficiency in Microsoft Word, Excel and PowerPoint
• Solid leadership skills; able to effectively manage a high performing team, provide coaching and development
• Demonstrated ability to adjust and shift priorities, multi-task, work under pressure and meet deadlines
• Proven ability to recognize opportunity for improvement and lead change
• Data analysis and trending skills
• Effective communication skills
• Prior supervisory skills
• Ability to work independently & in a team environment
• Training/teaching skills
• Time management skills
• Critical listening and thinking skills
• Strategic management skills
• Decision making/problem solving skills
• Customer service oriented

Licensure and Certification:

• Current, unrestricted Registered Nurse (RN) licensure in the state of practice is preferred
• Certified Professional in Healthcare Quality