The QI Manager is responsible for the leadership and oversight of the Quality Improvement staff and ensures that the department’s policies, procedures and workflows support optimal operations. The QI Manager works under the direction of the QI Director to ensure that the Quality Improvement functions are completed within established timeframes to maintain compliance with applicable regulations, policies and procedures.

• Provide leadership and oversight to assigned staff. Ensure that staff have adequate resources available.
• Monitor employee performance. Identify opportunities for improvement and/or professional development and facilitate coaching, counseling and training.
• Complete employee performance evaluations thoroughly, accurately and in a timely manner in accordance with company policy.
• Serve as the designee for QI Director and assist with coverage of Director tasks as needed.
• Manage the Appeals & Grievances (A&G) process and ensure that A&G’s are documented accurately and handled within established timeframes.
• Identify A&G trends. Analyze and track data and discuss findings with department management.
• Collaborate with the QI staff to fulfill requirements for all QI processes to include, Continuity of Care, Ambulatory Record Review/Safety Monitoring, Member and Provider Satisfaction Surveys, and Specialist Bonus programs. Evaluate the processes and identify opportunities for improvement.
• Manage and oversee the HEDIS measurement data collection through chart review and/or collaborating with contracted providers to obtain necessary documentation to meet the established goal.
• Participate in Provider orientations and trainings as requested and serve as a resource when new providers hired.
• Process Health Plan and member notifications for provider withdrawal, member non-adherence, behavioral issues, etc.
• Manage and maintain the medical group’s QI program, QI activity calendar and assist with work plan submissions to HPN and Health Plans.
• Review Heritage Provider Network (HPN) QI program for changes. Discuss changes with department management.
• Collaborate with the Credentialing Department and QI staff to coordinate record reviews for Provider offices and contracted ancillary facilities.
• Manage and oversee new employee departmental orientation.
• Assist with quarterly Quality Improvement Council Meetings including, but not limited to: agenda, minutes and policy and procedures updates.
• Review policies submitted by management. Present the submitted policies to the Quality Improvement Committee (QIC), stamp policy with QIC approval and send out notifications.
• Oversee and support the review of telephone calls and management etiquette call reports.
• Perform other duties as assigned.

• Graduate of an accredited nursing program.
• Current Registered Nurse (RN) License.
• Current California driver's license and proof of auto insurance coverage.
• 2-4 years of quality improvement (QI) and/or utilization management (UM) experience. 2 years of leadership experience, preferred.
• Knowledge of managed care systems. NCQA Standards and HEDIS. Computer
• Knowledge (Microsoft Word, Excel, Power Point, Access/databased program)
• Strong computer knowledge utilizing Word, Excel, Power Point.
• Excellent written and oral communication skills.
• Organizational -Detail oriented with critical thinking and problem solving skills.
• Excellent customer service and telephone etiquette skills