The MSO Quality Improvement Supervisor organizes and supervises the Quality Improvement program activities developed and implemented within the NEMS managed care structure; monitors QI projects and Care Based Incentives (CBI) programs implemented by CMS, DHCS and/or Managed Care Plans, including Practice Improvement Program (PIP), Pay for Performance (P4P), Quality Bonus Program (QBP), and other Quality Improvement programs and/or surveys/studies; prepares and participates in audits conducted by regulatory agencies regarding Clinical Quality, Patient Experience, and System Improvement; develops and revises policies and procedures for adherence to governmental and accredited agency standard. The QI Supervisor also responsible for collaborating with other departments/staffs in the preparation and development of the Quality Improvement Plans, coordinating HEDIS reporting activities, functioning as staff for the NEMS Clinical Quality Improvement Committee, assists in implementing effective and efficient standards, policies, protocols, and benchmarks that support QI operation.
The QI Supervisor works closely with the MSO Clinical Operation Manager, the Medical Director, and other internal clinical departments to ensure compliance with government, Health Plan(s) and contractual requirements as well as assists in the development and execution of programs to meet the goals of improving patient experience and health outcome.
ESSENTIAL JOB FUNCTIONS:
• Responsible for overseeing all aspects of quality improvement duties
• Monitors QI projects and Care Based Incentives (CBI) programs implemented by CMS, DHCS and/or Managed Care Plans, including
Practice Improvement Program (PIP), Pay for Performance (P4P), Quality Bonus Program (QBP), and other Quality Improvement programs
• Collaborates with other departments/staffs in the preparation and development of the Quality Improvement Plans; coordinates
improvement activities to meet QI goals
• Managing data collection and analysis for PIP, P4P, QBP, and other CBI; coordinates HEDIS reporting activities
• Prepares QI project evaluation reports including improvement activities, for timely submission to DHCS and/or Managed Care Plans
• Monitors outcomes of QI activities including collecting, analyzing and reporting appropriate statistical reports
• Presents QI project findings to stakeholders
• Supervises and implements staff training, including onboarding, systems, and policies and procedures pertinent to their quality
improvement duties and assignments
• Determines appropriate staffing requirements and develops processes to interview, hire, orient, train, evaluate, and recommend discipline
of subordinate staff
• Participates in the development and implementation of effective and efficient standards, policies, protocols, reports and benchmarks that
support the QI program; provides guidance on issues related to improving QI measures
• Participates in the MSO department program planning, team goal(s) setting, systems development and process improvement
• Performs Facility Site Review and Medical Record Review audits on participating providers
• Assists in performing case management duties
• Performs other duties as assigned
• Possession of a bachelor's degree in nursing from an accredited college or university, or an associate degree in nursing with 5 years’
experience in managed care utilization management setting.
• Minimum 4 years experience as a Utilization Review Nurse, discharge Planner, or Case Management Nurse in a managed care organization
(i.e. HMO, IPA, MSO)
• Minimum 3 years of supervisory experience or in a team lead position
• Experience with Medicare SNP programs is a plus
• Working knowledge of managed care and community resources and cultural needs
• Experience with health care coordination and/or health care case management models
• Demonstrate willingness to make decisions within RN’s clinical scope of practice; exhibit sound, accurate, and ethical judgment
• Demonstrate excellent detail oriented organizational, time management and interpersonal skills; ability to work with people from diverse
backgrounds and experiences
This is an FLSA exempt position.
This is an OSHA low risk position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.