PHYSICIANS MEDICAL GROUP OF SAN JOSE

JOB DESCRIPTION

Department: Quality Management / Reports To: Director of Health Services
JobTitle: Quality Management Manager / PositionCode: / Date: 01/2016

SUMMARY

The Quality Management (QM) Manager, as a registered nurse. Under the direction of the, Director of Health Services is responsible for the development, coordination and integration of quality management within EXCEL MSO/Physicians Medical Group of San Jose. Along with the Medical Director, QM Chairperson and the QM Committee implements the QM Program. The QM Manager supervises the QM staff.

ESSENTIAL DUTIES AND REPONSIBIILTIES include the following. Others may be assigned.

  • Prepare quality management policies and procedures as per health plan and regulatory requirements.
  • Coordinate all quality and risk management activities throughout the organization to promote a high standard of care and prevent duplication of effort.
  • Keep an accurate log of complaints, grievances, appeals, and Sentinel Events updating the data base with resolutions and closing dates.
  • Prepare agenda and minutes for the Quality Management Committee.
  • Follow through with requests from the QM Committee
  • Conduct/supervise the gathering of medical quality monitoring information for documentation, quality of care issues, trending, resolution and presentation.
  • Prepare data from quality monitoring activities for Committee review.
  • Develop/conduct member/provider satisfaction surveys, access surveys, and focus studies.
  • Develop and maintain quarterly reports, annual evaluation reports, annual QM work plans, etc.
  • Follow health plan protocols regarding member grievances/appeals.
  • Log, track, and report appeals and grievances, per health plan requirements, for the Quality Management Committee.
  • Act as a resource for QM committee and ancillary staff in quality and risk management issues.
  • Participate in health plan required studies and audits
  • Coordinate with health plans on quality initiatives, e.g., HEDIS, Gaps in Care Reports, Pharmacy Reports, Medicare Star Ratings and Initial Health Assessments and visits.
  • Gather data and analyze Medicare Hierarchy Condition Category (HCC) reports.
  • Develop and implement work plans based on Risk Adjustment Factors.
  • Gather and analyze ER data for report to Quality Management Committee and Utilization Management Committee.
  • Audit medical records and analyze results.

SUPERVISORY RESPONSIBILITIES

  • Manage 5- 8 non clinical staff

QUALIFICATIONS:

  • Licensed as a Registered Nurse in California is essential
  • Knowledge and experience of standard quality measures ( HEDIS, Medicare Star Rating, etc) is essential
  • Knowledge and experience with NCQA is essential
  • Knowledge on payment methodologies such as Risk Adjustmentis essential.
  • Knowledge of legal and medical requirements as applied to quality and risk management is essential.
  • Understand credentialing requirements and the utilization review process is preferred.
  • Experience in managed care setting, acute hospitals and management is preferred.
  • Have Baccalaureate degree in health care or related field and certification in health care quality preferred.
  • Previous claims/utilization experience preferred

TECHNICAL REQUIREMENTS

  • Experience with Microsoft Word, PowerPoint, and Excel are essential.
  • Experience with additional software related to NCQA or Risk Adjustment is preferred

BEHAVIORAL REQUIREMENTS

  • Exceptional organizational and analytical skills.
  • Ability to effectively, calmly, and pleasantly interact with both external and internal customers in difficult situations.
  • Clearly articulate plan benefits and managed care policies to members.
  • Maintain a good working relationship with physicians, patients and their families.
  • Maintain member confidentiality.

LANGUAGE SKILLS

  • Ability to write reports, business correspondence, and procedural manuals.
  • Ability to read, analyze and interpret specific quality data.
  • Ability to effectively present information and respond to questions among groups of managers, clients, providers, customers, and the general public.

MATHEMATICAL SKILLS

  • Ability to calculate figures and amounts.

PHYSICAL DEMANDS

  • Sit: possibly 90% of the workday.
  • Stand infrequently.
  • Use of computer keyboard frequently and intermittently throughout the day.
  • Lifting infrequent, up to 25 lbs weight.

Job Description/Quality Management Mgr.19/27/2018