The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

This position primarily is remote, onsite meetings or provider visits are required; Candidates MUST reside within distance of El Dorado, Stanislaus, or San Joaquin Counties.

What You Will Be Doing:

Under general supervision, the Supervisor of Quality Improvement is responsible for providing oversight of and coordinating daily operations for quality improvement, grievances and appeals consistent with internal and external requirements. Work is varied and moderately complex and requires a limited to moderate degree of discretion and independent judgment.

Supervises

Individuals supervised depends on area of focus:

• Grievance Coordinators
• Senior Appeals Nurse
• Grievance and Appeals Nurses
• QI Nurses

Essential Functions

• Plans and assigns work; monitors workload; makes timely and effective adjustments.
• Participates in HEDIS activities as required including but not limited to acting as clinical lead, performing overreads, and training on the HEDIS medical record review process.
• Oversees activities related to the Facility Site Review Process and may serve as the plan’s master trainer.
• Researches identified quality improvement issues related to HEDIS, MCAS, grievances and appeals; recommends interventions; leads planning and implementation, and evaluates outcomes.
• Oversees or conducts root-cause analysis investigations for specific patient care and network provider trends and all adverse effects; makes recommendations and implements action plans based on findings.
• Monitors and analyzes identified metrics; takes timely and effective action based on findings.
• Develops, implements and maintains unit policies and procedures; makes recommendations on revisions; communicates to appropriate individuals in a timely and effective manner.
• Compiles, develops and submits or oversees the compilation, development and submission of internal and external reports including the QI workplan, Program Description, and annual Evaluation of the QI program, FSR quarterly and annual reports.
• Leads external and internal quality and regulatory audits; assists in the development, implementation and monitoring of corrective action plans.
• Participates in state-wide collaboratives; assists with the planning, implementation, monitoring and reporting of the collaborative initiatives, PIPs, QIPs and PDSAs as outlined by DHCS or DMHC.
• Attends all FSR state collaborative meetings, monitors and implements all DHCS/DMHC regulatory changes, and intervenes when issue are identified.
• Serves as liaison to statewide and community agencies to identify and resolve program issues; assists with the preparation and delivery of reports on QIP activities.
• Serves as a non-voting member of the QIUM Committee; assists with the preparation and delivery of reports on QI issues, including effectiveness of correction action plans and annual QI Program Evaluation.
• Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission and values.
• Hires, supervises and retains a competent staff.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• Strong clinical skills at an RN/LVN level as defined in California scope of practice guidelines.
• In-depth knowledge and current NCQA/URAC standards; researches and remains current with a federal and state laws and regulations.
• In-depth knowledge of the principles and practices of quality improvement and grievance functions.
• In-depth knowledge of the healthcare issues affecting the underserved.
• In-depth knowledge of federal and state laws, standards and regulations, including Medi- Cal and/or Medicare and HIPAA, in managed care organizations.
• In-depth knowledge of and proficient skills in administering protocols.
• In-depth knowledge of audit processes, and the ability to effectively implement and maintain them.
• Basic knowledge of and ability to implement and monitor relevant metrics models.
• In-depth knowledge of data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity, and recognize and act on trends.
• Decision quality: Makes good and timely decisions that keep the organization moving forward.
• Action oriented: Takes on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.
• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
• Directs work: Provides direction, delegates and removes obstacles to get work done.
• Plans and aligns: Plans and prioritizes work to meet commitments aligned with organization goals.
• Optimizes work processes: Knows the most effective and efficient process to get things done, with a focus on continuous improvement; can develop, implement and maintain processes.
• Ensures accountability: Holds self and others accountable to meet commitments.
• Drives results: Consistently achieves results, even under tough circumstances.
• Organizational savvy: Maneuvers comfortably through complex policy, process and people- related organizational dynamics.
• Being resilient: Rebounds from setbacks and adversity when facing difficult situations.
• Courage: Steps up to address difficult issues, says what needs to be said.
• Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.
• Strong oral and written communication skills with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and conduct presentations.
• Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
• Ability to develop, implement and maintain processes, procedures and other guidelines.
• Strong collaboration skills, including but not limited to the ability to create and foster a collaborative work environment, and organize people and resources to solve problems and identify opportunities.
• Strong project management skills and demonstrated ability to lead complex initiatives.
• Basic knowledge of change management theory, with the ability to implement effectively.
• Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
• Strong supervisory and leadership skills, with the ability to supervise staff in a manner that maximizes employee performance and business results.
• Strong mathematics skills, including the ability to calculate ratios, perform simple algebra and statistical formulas.
• Ability to design workflow and procedures.
• Ability to develop and deliver relevant and effective training and supporting materials.
• Intermediate skills in Windows, Outlook, Word, Excel and PowerPoint.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

What You Have:

Education and Experience

Required

• Graduation from an accredited nursing school; and
• At least three years of clinical experience; and
• At least two years’ experience working with MediCal, Medicare or other state or federally sponsored programs in the areas of grievances and appeals; and
• At least one year as a supervisor; or
• Equivalent combination of education and experience.

Preferred

• Bachelor’s degree in Nursing, Business or closely related field
• Experience participating in facility site reviews and other HEDIS-related activities

Licenses, Certifications

Required

• Current unrestricted California Licensed Vocational or Registered Nurse license.
• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.

Preferred

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.