Senior Manager, Quality Improvement - Newark, NJ at Newark

Job Description

Senior Manager, Quality Improvement, RN Newark, NJ

WELLCARE HEALTH PLANS, INC.Performs oversight and management of Accreditation initiatives, state and regulatory quality compliance, HEDIS and quality improvement initiatives for performance improvement plans, quality improvement plans, quality improvement activities, delegation audits and external quality reviews; applies medical knowledge and analytical skills to effectively and efficiently coordinate quality activities and improve performance metrics of organizational goals.

*LI-CW1

Reports to:

State Medical Director,Field Quality Improvement

Position Location:

Newark, NJ

Essential Functions:

• Develops, implements and maintains a standardized quality management plan and program to ensure compliance with external regulatory and accreditation requirements.
• Establishes and maintains tracking and monitoring systems for health care quality improvement activities according to regulatory requirements, accreditation standards, policies and procedures and contractual agreements.
• Ensures high risk, high volume, and unusual events are monitored concurrently and retrospectively as they occur.
• Researches and develops performance measurement and outcome studies to assess and improve the health status of the membership. Plans, organizes and manages the design, development and analysis of a wide variety of topics relevant to health care services.
• Designs and develops methodologies for preventive care and health care evaluations. Researches and documents current health care standards for use in study design and methodologies. Conducts preventive studies to evaluate the continuity and coordination of care and to assess the quality and utilization of health care services. Provides assistance and guidance to clinical staff with regard to study design, methodology, data analysis and reporting.
• Manages and evaluate performance of staff related to clinical and health care services performance improvement activities. Provides department orientation to new staff and ongoing staff development to the entire department.
• Coordinates guidelines, studies and performance improvement activities in concert with the utilization management, quality management, pharmacy services, case management and disease management programs.
• Maintains a knowledge base of HEDIS requirements and implementing clinical performance methods to improve HEDIS performance.
• Prepares, compiles, reviews and submits monthly and quarterly reports for quality committee meetings.
• Coordinates all external programmatic oversight visits for contracted providers and ensures timely completion and follow up on corrective action plans.
• Participates in the development, review and updating of policies and procedures.
• Develops and analyzes reports to monitor and evaluate quality performance in meeting established goals related to quality improvement plan and contractual requirements.
• Provides guidance and training to new associates.
• Performs other duties as assigned.

Job Requirements

Education:

A Bachelors Degree in Health Care, Nursing, Public Health, Health Administration or directly related field; a Masters Degree in a related field preferredLicense:

Unrestricted Registered Nurse (RN) License required

Experience:

• 7 years of experience in directly related Quality Improvement job duties
• 4 years of experience in Managed Healthcare
• 2 years of management experience
• Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards
• Experience with Medicaid/Medicare
• Knowledge of community, state and federal laws and resources

Special Skills:

• Demonstrated written communication skills
• Demonstrated interpersonal/verbal communication skills
• Demonstrated analytical skills
• Demonstrated problem solving skills
• Ability to work in a fast paced environment with changing priorities
• Ability to multi-task
• Ability to effectively present information and respond to questions from families, members, and providers
• Ability to effectively present information and respond to questions from peers and management
• Ability to lead/manage others
• Ability to influence internal and external constituents

Technical Skills/Requirements:

• Intermediate proficiency in Microsoft Word, Excel, PowerPoint, Visio, and Outlook
• Experience with Healthcare Management Systems

Country: USA, State: New Jersey, City: Newark, Company: WellCare Health Plans Inc..