Manager, Provider Quality Oversight

Role Overview

• Leading the daily operations of the Potential Quality Incident/Provider Preventable Condition and clinical reporting nurse teams.
• Ensure the complete review of Quality-of-Care cases, adherence to standard work, reporting accuracy, and compliance with IEHP policies, Local, State, and Federal laws, and regulations.
• The planning and implementation of any quality audit initiatives, programs, and processes identified by IEHP’s Quality System.
• Responsible for managing direct reports to ensure effective resource management and prioritization of work in support of meeting Quality and Organizational goals and priorities.
• Responsible for the development, management, implementation, and evaluation of all areas of responsibility including, but not limited to, Potential Quality Incidents (PQI)/Provider Preventable Conditions (PPC) processes, Quality Reviews, and clinical audits of IEHP Providers to ensure clinically appropriate billing.
• Provide oversight and management of the PQI and PPC processes and staff to comply with IEHP policies, Local, State, and Federal standards, and regulations.
• Collaborate with appropriate internal and external departments, team members, and entities to achieve organizational quality initiatives, as assigned.
• Responsible for the development, maintenance, implementation, and adherence to departmental policies and procedures, standard operating procedures, and job aides.
• Participate in Quality Management activities and projects to ensure interventions meet project goals.
• Lead, prepare, and coordinate appropriate Provider Quality Review department related internal meetings.
• Represent IEHP in external meeting related to key areas of responsibility as appropriate.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance.

Requirements

• Five (5) or more years of any individual or combined healthcare experience in quality management, quality assurance, quality improvement, utilization management, case management, acute care, and/or ambulatory care setting
• Three (3) or more years of experience in a supervisory or leadership role in any healthcare setting
• Experience in an HMO or Managed Care setting is preferred
• Bachelor's degree in Nursing from an accredited institution required
• Master's degree in Nursing from an accredited institution preferred
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required
• Certified Professional in Healthcare Quality (CPHQ) certification preferred
• Knowledge of clinical audits, including medical record reviews
• Intermediate knowledge of word, excel, and PowerPoint.
• Intermediate computer skills
• Excellent verbal and written communication skills
• Builds effective work relationships

Benefits

• CalPERS retirement 457(b) option with a contribution match
• Generous paid time off
• vacation, holidays, sick
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Paid life insurance for employees with additional options
• Short-term, and long-term disability options
• Pet care insurance
• Flexible Spending Account – Health Care/Childcare
• Wellness programs that promote a healthy work-life balance
• Career advancement opportunities and professional development
• Competitive salary with annual merit increase
• Team bonus opportunities