Manager, Provider Quality (RN)

Job Summary

The Manager of Provider Quality is directly responsible for the organization, direction and staffing of L.A. Care's Credentialing/Peer Review Committee, Peer Review and Potential Quality Issues (PQI) reviews, committees and functions. Responsibility includes regulatory compliance, oversight of plan partner/specialty health plan related operations, operations for direct lines of business and/or management services agreement functions, and interfacing with external agencies including other Local Initiatives, Plan Partners, Specialty Health Plan and Community Based Organizations.  Critical to the position is ensuring that the information is protected and processes are developed and implemented in accordance with regulatory and legal statutes. The Manager is further responsible to assure all functions are operating in accordance with the organization's mission, values and strategic goals and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership.  Manages all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Develop goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. 
 
Manage the Provider Quality Review processes and staff.  Ensure initial and  follow up reviews are completed, reported and tracked accurately in a timely manner, including day to day activities related to, management and monitoring of nurses, and support staff.
     
Oversees and evaluates operational compliance with organizational standards, policies and procedures, and regulatory requirements. Researches and designs appropriate organization-wide performance and quality training.   
 
Develops and maintains department statistical and performance reports, assures the integrity of the information and ensures that proper communication with internal and external stakeholders occurs. Where clinical concerns with providers exist, manage the development and monitoring of action plans to improve performance.      

Reports appropriate information to appropriate committees and the governing body.
       
Performs ongoing monitoring and evaluation of departmental operations to assure optimal efficiency and effectiveness. 

 Communicates any barriers to completing assignments or daily work in an efficient and effective manner while maintain confidentiality in compliance with all HIPAA requirements.         

Performs other duties as assigned.  

Duties Continued

Education Required

Education Preferred

Experience

Required: 
At least 6-8 years quality improvement or peer review or credentialing experience in health care organization, preferably from an HMO/managed care organization.

At least 3-5 years of supervisory/management experience.

Skills

Required: 
Extensive knowledge of National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services(CMS), DHS and Health Plan standards, and a high level of responsibility for disciplinary proceedings.

Must be knowledgeable about state requirements for credentialing.

Analytical, detail oriented, proficient in time management, ability to multitask projects; managed and supported committees.

Excellent written/verbal and organization skills as well as interpersonal skills.

Must be proficient in Excel, Word and Access.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information