Quality Program Manager, Health Plan

Richmond VA 23233

Job Description

Responsible for the resolution of potential quality of care issues. Reviews documentation and interprets data obtained from clinical records to apply appropriate level in line with regulatory and accreditation requirements for potential quality issues. Documents and summarizes for health plan and national leadership the issues, recommended course of action and the results.

Essential Functions

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  • Supervises quality staff focused on potential quality of care issues and patient safety activities within the plan
  • Assumes responsibility for monitoring all sentinel events and member concerns reported for potential quality of care issues
  • Develops process to maintain ongoing assessment and evaluation of provider site complaints, medical record keeping standards, continuity and coordination of care standards and clinical guidelines in support of QI activities, in accordance with NCQA standards, including the approval process, distribution, data collection, analysis and revisions as necessary
  • Creates database to support trending and reporting of adverse outcomes resulting from clinical care provided
  • Develops reports and analysis for monthly trending reports and presents to the National Quality committee to obtain input and recommendations
  • Develops data collection tools in accordance with state, federal and accreditation standards
  • Ensures chart reviews are conducted to determine if a potential quality issue has occurred
  • Develops policies and procedures in accordance with state, federal and accreditation standards; reviews and updates as required
  • Presents results that include analysis and trending to the National Quality committees
  • Ensures that corrective action plans are implemented as needed per policy guidelines
  • Oversees that documentation is in accordance with contractual requirements

General Job Information

Title

Quality Program Manager, Health Plan

Grade

27

Job Family

Quality Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

2/5/2019

Date Requisition Created

1/21/2019

Minimum Qualifications

Education

Bachelors: Healthcare (Required), Masters: Healthcare

License and Certifications - Required

LPN - Licensed Practical Nurse - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Other Job Requirements

Responsibilities

Preferred Qualifications

  • Master’s degree in related discipline or equivalent work experience 
  • Demonstrated experience in leading significant cross-functional work 
  • Management/supervisory experience
  • Experience with appeals, critical incidents and sentinel events
  • Ability to manage relationships with an emphasis on internal and external mid-level relationships 
  • Ability to work across all levels of the organization, including working with executive audiences, vendors and the government as a customer 
  • Demonstrated ability to select and implement strategies that are most likely to be successful 
  • Seven plus years experience in managed care 

Required Qualifications

  • Bachelor’s degree in healthcare or related discipline 
  • Five plus years of experience in quality management 
  • LPN or RN 
  • Demonstrated understanding of healthcare industry standards, HEDIS and NCQA 
  • Proficient in Microsoft Office tools 
  • Strong analytical skills and strategic thinking 
  • Strong communication skills, both verbally and written 
  • Ability to interact effectively with business owners, senior management, and peers across the organization 

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled

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