Competitive Compensation & Benefits Package!

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs

Primary Purpose of Position: This position performs Quality Management, Quality Assurance (QA) and Quality Improvement (QI) activities to encompass monitoring and quality oversight for maintaining and improving the LME/MCO with regards to overall performance. This includes but is not limited to: reporting, surveys, trend analysis and audits to ensure compliance of operational policies.

Role and Responsibilities:

• Tasks may include but not limited to:
• Quality Improvement Projects
• Process Mapping
• Lean Six Sigma projects
• Internal Audits and Quality Oversight:
  • Provider Network
  • Utilization Management
  • Partners Access
  • Consumer Rights
  • Care Coordination-MHSU and IDD
  • Compliance and Quality Management
  • System of Care
  • Tailored Plan/Medicaid Direct Contracts, Accreditation and External Review for regulatory, contractual, and accreditation compliance
  • Policies, Procedures, Plans & Program Descriptions
  • General Audits as identified with Subject Matter Experts
• Quality Assurance Activities
• Ensures integrity of data through quality checks and vetting of information in a systematic, industry acceptable standard/methodology
• Verifies compliance of Plans of Corrections, as appropriate.
• Processing, tracking and facilitation of Partners grievances protocols and processes as applicable
• Assist in annual QM Evaluation data collection, development, delivery
• Participates and/or Facilitates QM team responsibilities as a group
• Assists LME/MCO departments with development and implementation of outcome performance progression and compliance with external contract directives and accreditation mandates.
• Provides essential performance information to include data and reports to Management Team to include, Chief Performance and Compliance Officer, Quality Director, as well as QM Team members and external stakeholders.
• Communicates training initiatives as needed for management and delivery of QM Department /Tailored Plan organizational deliverables.
• Provides technical assistance to departments as follow-up to findings.
• Assist in development, dissemination and analysis of provider, consumer, staff, and stakeholder surveys for quality assurance and performance improvement purposes.
• Assist in developing remediation plans or activities based on evaluations of survey or audit results, i.e. CAPHS, Member Surveys, External Quality Review Organization (EQRO) Corrective Action Plans (CAP’s), Accreditation Plans of Correction (POCs)
• Develop internal process evaluations to ascertain organizational compliance and quality customer service provision and influence change when applicable through the performance improvement projects. Maintains effective work relationships with LME/MCO staff, Partners BHM departments overall with a focus on State and Community Stakeholders to assure needs and concerns of the organizational community are effectively and impartially addressed.

Quality or Performance Improvement Activities

• Identifies through detailed data analysis and overarching global review, the need for performance improvement projects, develops and recommends project plans, monitors progression, trends, gaps, and opportunities for continued improvement.
• Coordinates performance indicator reports; conducts research as applicable.
• Reports findings to organizational leadership as designated.
• Conduct specialized reviews, inquiry, investigations, focused studies and research projects to include analysis or interpretation of such activities.

Other QM Activities

• Assists in organizational quality review processes as appropriate.
• Participates on Quality Committees as delegated.
• Participates with QM internal department goal and outcome initiatives.
• Participates in all duties as delegated and applicable.

Knowledge, Skills and Abilities:

• Considerable knowledge of the Quality Management and Quality Assurance process and philosophies to include knowledge of TP/Medicaid Direct Plan Departmental activities such as Provider Network, Utilization Management functions.
• Demonstrated knowledge and skills in the areas of data reporting and dissemination to facilitate performance monitoring and oversight for QM Team and Tailored Plan departments
• Computer software knowledge, usage and operational skills required to complete tasks, i.e. Proficiency in EXCEL.
• Highly skilled in problem solving, data and information analysis
• Ability to synthesize data and information efficiently and effectively
• Ability to understand needs and concerns of QM Team, Tailored Plan Departments, Executive and Management Leadership, National Accrediting Organizations and State/Community Stakeholders.
• Ability to implement and facilitate communication, outcome resolution and quality standardization/evaluation when applicable through the MCO partnerships

Education/Experience Required: Bachelor’s Degree and 2 years of experience in Quality Management or a related area in data collection, reporting and/or analysis or an equivalent combination of education and experience.

Education/Experience Preferred: Concentration in Quality Management or related area and two [2] years of experience in collecting, reporting and analyzing data in a Human Service/healthcare setting. Lean Six Sigma- Greenbelt Certification

Licensure/Certification Requirements: N/A