2 Clinical Programs Director - Quality and Utilization Management Jobs in Los Angeles, CA
KP Recruiting Group is Hiring a Clinical Programs Director - Quality and Utilization Management Near Los Angeles, CA
KP Recruiting Group is a consulting firm that providesleadership and exceptional talent to some of the world’s leading companies.Headquartered in the Midwest, KP Recruiting Group has successfully completedcountless engagements in the United States, Europe and Latin America. Werepresent clients in all industries and all sizes. Our mission is to provideexceptional client and candidate experiences in order to get the best possibleresults. On behalf of our client, we are excited to present the following confidentialrole. We look forward to hearing from you and discussing the opportunity!
The Role:
- PROGRAM ACCOUNTABILITIES:
- Lead the quality and utilization management programs for all LOBs. This includes unique relationships held whereby quality and utilization is a delegated function to other delegated entities
- Assure that policies and operating procedures are comprehensive, implemented and reviewed annually
- Analyze and interpret data, assessing impact on care or service. Develop potential interventions and cost/benefit of such interventions. Prepare and present periodic reports on specific areas of health services utilization as directed. Report performance, both activity volume and outcome, on a monthly and year-to-date basis, assessing for improvement opportunities
- Prepare and present evidence of quality and utilization compliance for payer and regulatory audits and accreditation surveys
- Evaluate components of Clinical Programs Management; i.e. utilization management and quality management as appropriate to area of responsibility at least annually and assess for improvement opportunities
- Assist in external contracting for delegated services
- Research potential quality of care issues, assessing for system problems as well as individual, case specific issues
- Responsible for oversight of delegated quality programs
- Assist in the development, implementation, and maintenance of the provider reporting, which incorporates utilization, quality, and credentialing data. Collaborate with the credentialing and quality committees to ensure that provider performance monitoring is effectively handled
- Oversee the quality of care complaint handling process ensuring that it is timely and compliant with external requirements
- Develop action plans for health plan quality measurement programs, such as CMS 5 Star, NCQA commercial ratings, Marketplace Quality Rating System, and Health Share incentive measures
- DEPARTMENT MANAGEMENT AND HUMAN RESOURCES FUNCTIONS:
- Management of staff, which includes goal setting, hiring and terminating, training, performance evaluations, the development of corrective action plans, and monitoring for improvement
- Identify training needs and provide for the development and continuing education of professional staff to ensure competency
- Act as a mentor and provide consultation to staff in quality and utilization management
- ACCREDITATION AND REGULATORY REQUIREMENTS:
- Assure that applicable regulatory and accrediting requirements are met in a timely and professional manner. Prepare fully for all regulatory and accrediting agency audits and reviews
- Develop and monitor corrective action plans and project action plans, reporting to management and committees as appropriate
- Identify and implement tools that assure compliance with DMHC, CMS,, NCQA and other regulatory and accrediting agencies
Requirements
Master's Degree in Public Health, Healthcare Administration, Business Administration or relevant
Minimum 7 years Management experience including 7 years supervisory or leadership experience
Benefits
Ourclient offers a comprehensive benefits package including:
401kMatching
Family andIndividual Insurance Packages (Health, Life, Dental, and Vision)
Paid TimeOff & Paid Holidays
Long &Short-Term Disability
IdentityTheft Plans
Retirement& Pension Plans
EmployeeAssistance Program
EmployeeReferral Program
TuitionReimbursement Programs
Advancement& Professional Growth opportunities
ParentalLeave
& More
Job Summary
Full Time
Business Services
$148k-186k (estimate)
03/10/2024
06/06/2024
kprecruiting.com
Minneapolis, MN
<25
Business Services
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