Description

Hybrid: Applicants must be a California resident as of their first day of employment.

PRINCIPAL RESPONSIBILITIES:

The Quality Improvement Clinical Manager is responsible for overseeing clinical safety activities to ensure compliance with regulatory requirements and the continuous improvement of quality of care and services. This role requires collaboration with various departments to address quality concerns, implement corrective action plans, monitor the effectiveness of interventions, and process improvements for efficiency and effectiveness of operational processes. Clinical safety activities pertaining to the Quality Improvement Health Equity (QIHE) Program includes Facility Site Review (FSR), Grievance & Appeals (G&A), Potential Quality Issues (PQI), Provider Preventable Conditions (PPC), quality of care corrective action plans, and clinical activities to improve the quality of care/service for members.

Principal responsibilities include:
• Oversee operational and tactical strategies for clinical safety activities to promote detection, prevention, and remediation.
• Lead cross-functional meetings to address system trends based on monitoring issues, findings, or analysis of clinical safety activities and other data points
• Develop and implement process improvements or workflows relating to FSR, PQI, PPC, G&A or other related clinical quality activities that improve efficiency or effectiveness
• Collaborates with other departments (i.e. Provider Services, Compliance, etc.) for cases requiring escalation and/or address barriers to ensure timely closure of corrective action plans
• Manages the Skilled Nursing Facility/Long Term Care (LTC) quality monitoring program in collaboration with the LTC to ensure safe care for members
• Manages ad hoc chart reviews to assess, address, or monitor quality of care issues, trends, regulatory audit findings, or strategic priorities
• Contributes toward clinical key performance indicators at Joint Operating Meetings
• Conducts cross-functional root cause analysis and action plans to address quality of care issues
• Develops inter-rater reliability and quality assurance processes to ensure accuracy, appropriateness, and competency to process PQIs and Grievance and Appeals cases
• Develops, updates, and maintains policies and procedures, standard operating procedures, and other operational documents pertaining to the clinical safety unit
• Contributes to the Quality Improvement Health Equity (QIHE) Program trilogy documents (evaluation, program description, and workplans) and related documentation
• Facilitate clinical quality oversight through periodic reviews, chart audits, and reporting of key performance indicators.
• Addresses complex quality of care problems and facilitate an integrated approach to improvement initiatives
• Develops a comprehensive approach to achieving internal and external standards for quality and clinical safety.
• Develops and maintain dashboards for providers with defined expected outcomes & benchmarks based on clinical quality
• Provide contributions and clinical expertise relating to quality measures (i.e. HEDIS), Performance Improvement Projects (PIPs) and Quality Improvement Projects (QIPs), and other strategic initiatives
• Provides in-person and/or virtual training on clinical processes to support clinical safety initiatives
• Manages staff to ensure adherence of policy and procedures, standard operating procedures, and regulatory requirements
• Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB
• Data collection, measurement, maintenance, and analysis.
• Report and presentation development to support regulatory submissions.
• Coordinate and consult with Alliance departments on clinical quality improvement activities
• Keep abreast of healthcare industry best practices and managed care regulatory requirements.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Train, supervise and audit staff performance

PHYSICAL REQUIREMENTS
• Constant and close visual work at desk or on a computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Frequent use of telephone headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and various other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional driving of automobiles.

Number of Employees Supervised: 7-10

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:
• California licensed Registered Nurse.
• Bachelor's degree in health-related field preferred. BSN is strongly preferred.
• A Master's degree may substitute for two years of the required experience, or an equivalent combination of education and experience which would provide the required knowledge, skills, and abilities may be qualifying

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
• 4 years of experience in a managed care organization.
• Experience in FSR, PQI, G&A, quality management, patient safety, or care coordination strongly preferred.
• Previous experience in a leadership role required.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
• Ability to work collaboratively with physicians, staff and external organizations to improve quality outcomes.
• Strong communication and presentation skills, training/meeting facilitation skills a plus.
• Solid relationship building and interpersonal skills.
• Excellent writing, research, analytical, and time management skills.
• Excellent coordination skills, including multi-tasking and setting priorities on work assignments.
• Ability to organize and coordinate various activities involved in a research, collaborative and demonstration project.
• Knowledge of managed care organization practices, policy, programs, initiatives and functions.
• High degree of independence, flexibility, initiative and commitment.
• Ability to work effectively with diverse populations, both internally and externally.
• Solid critical thinking and problem-solving skills.
• Ability to utilize sound judgment and promptly report potential risks.
• Ability to work in a fast paced, patient-service oriented environment.
• Demonstrate Ability to promote quality improvement through development and maintenance of standards.
• Ability to handle PHI and maintain confidentiality at all levels.
• Proficiency in Windows including Microsoft Office suite including Word, Excel, and PowerPoint.

SALARY RANGE $167,440.00 - $251,160.00 ANNUALLY

Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/ classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the Human Resources department.