Job Description
JOB DESCRIPTION
JOB TITLE: Director, Quality
Improvement and Risk Management
STATUS: Exempt Full-Time
REPORTS TO: CEO
This job description is intended to be a general statement about this job and is not to be considered a detailed assignment. It may be modified to meet the needs of the organization.
JOB SUMMARY
Responsible for developing, implementing and monitoring quality management policies and procedures for quality data collection and reporting on HEDIS, UDS, Meaningful Use and PCMH measures. In addition, this position is also responsible for developing, implementing and monitoring the population health program and staff who will outreach to all active patients to encourage them to get their necessary visits done and to outreach specifically to high-risk clinic patients to help them get the needed visits, prescriptions, tests, education and procedures they need to improve their health status. This position will also work closely with the Executive Director on any additional quality measures the clinic chooses to pursue.
The QI/Risk Manager provides strategic and operational leadership pertaining to compliance and regulatory issues including but not limited to Human Resources, Finance, Clinical and Operations. The position oversees the development of a risk management program to assess, prioritize, and manages legal and regulatory compliance risks based on state/federal guidelines and requirements and benchmarking research, facilitating the systematic assessment and management of risks.
The role is also responsible for organization-wide confidential reporting systems allowing employees, patients, contractors, and other stakeholders to disclose violations of the Clinic's ethical standards, violations of law, or policy relating to such matters without fear of retaliation.
This position is a supervisory position and responsible for the selection and supervision of the Patient Navigators. This position will also work closely with the quality staff at the Council of Clinics IPA on their quality measures for IBCC's managed care patient population. This position staffs the monthly CQI meetings, preparing the agenda, quality reports and minutes, in conjunction with the Chief Medical Officer.
ESSENTIAL JOB FUNCTIONS
Conduct ongoing assessments of the existing eligibility and referrals, case management, disease management systems, and Quality Management and Risk Management programs. Provide objective evaluation and recommendations for those systems.
Review existing clinic information system capabilities for the tracking and monitoring of quality indicators. Make the necessary adaptations for standardized reporting across all clinics.
Responsible for development, implementation and ongoing refinement of organization-wide strategies for an effective compliance, ethics and integrity and privacy/security program
In collaboration with the Compliance Officer, develops, directs and maintains responsibility for the Clinic's compliance function and business ethics related to standard of conduct, including HIPAA/Hitech privacy and security compliance
Reviews the content and performance of the Clinic Compliance Program including Medicare Part D, compliance policies and procedures, and the Code of Conduct on a routine basis and takes appropriate steps to ensure its effectiveness to prevent, detect and correct illegal, unethical, or improper conduct within the corporation
Manages any investigations of alleged violations of law, policies and procedures, and the Clinic's Code of Conduct in consultation with the Compliance Office and General Counsel, and/or designated outside legal counsel, and takes appropriate corrective action
Identify best clinical and business practices within the clinics. Recommend standardized systems and develop a plan to implement and monitor systems within and across the member clinics.
Develop and maintain effective work plans to implement the IBCC Quality Management plan within each clinic.
In cooperation with the Chief Medical Officer , develop clinical quality indicators that will be monitored for all clinics.
Work with the IT department in the development of strategic and tactical plans to support the Quality Management program. Provide insights and real-world experience as the plan is developed to ensure ease of information technology access/utilization in the clinics.
Effectively communicate the goals and objectives of the Quality Management and Risk Management program to each clinic's staff, the Chief executive Officer and Chief Medical Officer. Provide the necessary training and skills to effectively perform the activities outlined in the QI/RM program.
Lead and provide administrative support to the clinic's Quality Management Committee.
As part of the Quality Management Committee, standardize the data collection process by establishing regular data entry procedures, reporting policies and assessment guidelines that will be implemented at each clinic.
Oversees the development, implementation and maintenance of an effective compliance communication and training program for the organization, subsidiaries and affiliate entities
Effectively translates regulatory guidance into streamlined operational processes to ensure compliance, at times with short notice
Manages the development and operation of the organizations compliance hotline and works with the CEO and Compliance Officer and/or designated outside legal counsel to resolve legal compliance issues, and works with Human Resources to resolve employee-related issues, as appropriate
Designs and implements programs, policies, and practices to ensure that all business units are in compliance with federal, state, and local regulatory requirements
Tracks laws and regulations that affect the organization's policies. Prepares compliance reports for presentation to the Board of Directors and executive management
Directs the coordination and completion of all government, regulatory, and compliance documents on an organization level and oversees the acquisition and maintenance of required licenses and certificates from appropriate state and federal entities
Provide the clinical and continuous quality improvement expertise in meeting disease management grant objectives.
Establish a standard reporting program for utilization, quality and risk management indicators.
Assist the clinics in the development of Disease Management programs that are targeted in the Quality Management Work Plan.
Report audits requiring clinical judgment and expertise to the Chief Medical Officer of clinics, Quality Management Committee and other entities, as assigned.
Review and analyze reports from managed care health plans to identify utilization and case management areas for improvement.
Ensure compliance with health plan utilization and Quality Management requirements.
Assist clinics in working with hospital emergency room and discharge planners to improve the continuity of care for CCHN clinic patients.
Establish effective clinical information linkages with specialists and other agencies providing services to IBCC clinic patients.
Complete Annual job performance reviews for all persons supervised,and provide feedback on job performance.
Other duties, as assigned.
QUALIFICATIONS
Skills
Must demonstrate effective interpersonal skills and sound clinical judgment in dealing with Medical Directors, mid-level providers and clinic staff. Must possess strong understanding of QM/CQI practices, procedures and tools. Should be able to effectively identify opportunities for process improvements to maximize the quality and cost-effectiveness of patient care.
Must demonstrate strong project management skills with an emphasis on gaining support from others for cross-organization programs/initiatives. Must have capacity to work independently and view challenges as learning opportunities. Strong working knowledge of relevant computer programs and medical information systems is required. Must possess valid driver's license, insurance, and provide own reliable transportation for work use.
Education/Experience
5 to 10 years of job-related management experience in the healthcare environment. Candidates with other healthcare experience (health plans, state Medicaid plans) may be considered
Bachelor's degree in a business, health care or related area of study required (or equivalent combination of education and experience); an advanced degree is preferred.
HIPAA compliance experience preferred
Experience with broad spectrum regulatory issues is a must
Solid computer skills with Microsoft Office/Outlook, industry-related databases and use of the internet
Knowledge of Medicare/Medicaid and related healthcare rules and regulations, such as third party administrator and utilization review
PHYSICAL REQUIREMENTS
Ability to sit or stand for long periods of time
Ability to reach, bend and stoop
Physical ability to lift and carry up to 20 lbs.
HIPAA/COMPLIANCE
Maintain privacy of all patient, employee and volunteer information and access such information only on as need to know basis for business purposes.
Comply with all regulations regarding corporate integrity and security obligations. Report Unethical, fraudulent or unlawful behavior
Job Type: Full-time
Pay: $120,000.00 - $160,000.00 per year
Job Tags
Full time, For contractors, Local area,