Senior Manager, Clinical Quality Improvement

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

This position reports to the Senior Medical Director, providing support and leadership to the comprehensive quality improvement program. The Senior Manager, Clinical Quality Improvement  has oversight of quality and clinical health initiatives for the health plan. This position works with organizational leadership and external entities to ensure that the QI program effectively measures, evaluates, and continuously improves the quality of care and service provided to members. 

The Senior Manager, Clinical Quality Improvement  will collaborate with the Senior Director, Quality Improvement and QI team in designing and implementing clinical quality improvement strategies and contribute to the overall Quality Improvement and Health Equity Transformation Program by identifying issues, implementing corrective actions, and optimizing GCHP performance. This position will collaborate with key stakeholders and internal departments to achieve the goals of the quality improvement program.

Amount of Travel Required: 10-15%

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

•    Manages, mentors, trains, and conducts performance evaluations for designated personnel within the QI department.

•    Leads team to implement QI initiatives that impact the clinical quality or effectiveness of health care services provided to members, ensuring compliance with accreditation, state and regulatory requirements.

•    Monitors, analyzes, and reports on outcomes to ensure goals, performance targets, and regulatory requirements are met.

•    Serves as subject matter expert (SME) for clinical QI activities, including problem identification, data and root cause analysis, recommendations, and action plans.

•    Utilizes clinical expertise to create and/or revise policies and procedures, establish work plan metrics and key performance indicators, implement provider training programs, and develop member and provider newsletter and website content. 

•    Provides clinical leadership for QI activities, including medical record reviews, facility site review, provider audits, investigation of potential quality issues and provider preventable conditions, and HEDIS®. 

•    Provides oversight and guidance to the monitoring and execution of regulatory clinical quality activities, including but not limited to facility site reviews, initial health appointments, and blood lead screening.

•    Analyzes performance metrics related to clinical or operational performance in order to recommend quality improvement strategies, which may include but not be limited to clinical measure prioritization, service quality, member/provider feedback and health equity initiatives. 

•    Participates and/or provides oversight to regulatory compliance activities including but not limited to DHCS Medical Audits, HEDIS® compliance audits, and internal/external audits.

•    Manages, facilitates, or participates in rele