Job Summary:
This position is responsible for leading all aspects of quality management compliance for client. This includes compliance auditing and reporting, and complaint resolution.
Responsibilities:
- Directs staff to support quality improvement and initiatives specifically related to Quality Audit, State Complaints, Complaint Resolution, to ensure appropriate staffing and effective operation.
- Oversees Quality Management compliance and URAC/NCQA and NJ State EQRO (currently IPRO) and provides leadership to ensure attainment of high accreditation standards.
- Develops and implements strategies for quality improvement and initiatives.
- Responsible for assuring timely correction of deficiencies, identification of problem providers and promptly reports difficulties or lack of cooperation to the Director of Quality Management.
- Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.
- Works with Utilization Management to develop related policies and procedures.
- Participates in special projects as assigned by the Director, Quality Management.
- Provide leadership and utilizes professional and communication skills to direct and motivate staff to ensure high quality outcomes.
- Represents the Plan with external customers, providers and external agencies and represents the unit on corporate issues and/or in the event of Director's absence.
- Manage, direct, and develop staff by providing feedback and coaching. Administer performance, and salary review for staff.
- Ensure staff meets all regulatory requirements and utilizes best practice methodology.
Knowledge:
- Requires working knowledge of NCQA accreditation standards.
- Requires thorough knowledge of managed care products and benefit contract agreements.
- Requires knowledge of HEDIS, CAHPS, and QAPI for CMS.
- Requires the ability to think analytically and to use logic in the solving problems.
- Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint & Outlook); Should be knowledgeable in the use of intranet and internet applications.
Skills and Abilities:
- Requires excellent verbal and communication skills.
- Requires strong project management skills.
- Requires strong organizational skills.
- Requires strong problem solving and decision making skills.
- Requires good analytical skills.
- Requires strong relationship building skills to work collaboratively across departments/divisions.
Education/Experience:
- Requires a Bachelor's degree from an accredited college or university.
- Requires five (5) years managed care experience.
- Requires a minimum of five (5) years quality management experience.
- Requires minimum of five (5) years management experience.
- Requires project management experience.
Additional licensing, certifications, registrations:
- Requires a Registered Nurses license in the State of New Jersey.
Thanks & Regards,
Nishit
732-429-1639
