Manager, Health Plan Quality Programs

Job Summary:

Manages the development of quality strategies in alignment with KFHP strategic priorities, mission, and vision. Manages the teams coordination across areas to recommend actions based on reviews of regional quality reports. Guides the identification of new opportunities for improvement and establishes team priorities. Leads the implementation of clinical quality improvement action plans and puts forth recommendations to senior leadership. Determines accountability areas for team members, ensures quality issues are identified and resolved, and takes action on escalated issues from team members. Serves as a subject matter expert for clinical quality processes and regulations for team members and leverages processes and tools for others to increase their regulatory knowledge. Manages others to review and act on results of data analysis, monitor corrective action plans, and review and approve quality policies. Guides the oversight of and coordination with the functions of Quality Committees and subcommittees. Leads the annual approval of Quality Program description, work plans, and annual evaluations.

Essential Responsibilities:

+ Provides developmental opportunities for others; builds collaborative, cross-functional relationships. Solicits and acts on performance feedback; works closely with employees to set goals and provide open feedback and coaching to drive performance improvement. Pursues professional growth; develops and provides training and development to talent for growth opportunities; supports execution of performance management guidelines and expectations. Leads, adapts, implements, and stays up to date with organizational change, challenges, feedback, best practices, processes, and industry trends. Fosters open dialogue amongst team members, engages, motivates, and promotes collaboration within and across teams. Delegates tasks and decisions as appropriate; provides appropriate support, guidance, and scope; encourages development and consideration of options in decision making.

+ Manages designated work unit or team by translating business plans into tactical action items; oversees the completion of work assignments and identifies opportunities for improvement; ensures all policies and procedures are followed. Aligns team efforts; builds accountability for and measuring progress in achieving results; determines and ensures processes and methodologies are implemented; resolves escalated issues as appropriate; sets standards and measures progress. Fosters the development of work plans to meet business priorities and deadlines; obtains and distributes resources. Removes obstacles that impact performance; identifies and addresses improvement opportunities; guides performance and develops contingency plans accordingly; influences teams to execute in alignment with operational objectives.

+ Serves as the subject matter expert for clinical quality improvement processes and regulations within assigned teams, departments, and facilities by: providing consultation on the interpretation and interaction of current policies and how they interact with the current climate, and potential changes to regulations and legislation; serving and leading on committees, projects to influence decisions on the enforcement, development of policies, or procedures of regulations and auditing processes and ensuring successful implementation of core priorities; fostering collaborative, results-oriented partnerships with practitioners, staff, and/or management across clinical and administrative roles to ensure credentialing regulations are followed and providing insight to the regulation climate; initiating the development of educational programs to raise awareness for current and changes in regulation requirement, internal concerns, and system/database usage; and empowering team to anticipate issues, weigh practical and technical considerations in addressing issues, and coordinate with the appropriate stakeholders to develop resolutions.

+ Manages the quality of care complaints and review by: directing the grievance meetings, cases, reviews, referrals, and other mechanisms by collaborating with key stakeholders, the ombudsman, and external regulatory services; responding to and directing the preparations of all documentation, records, and information requested; analyzing and managing the process flow of investigations and claims for potential errors, red flags, and areas of improvement; and monitoring critical quality improvement metrics, cases, quality care incidents, and near misses according to established protocols on a periodic basis.

+ Leads the development and implementation of infection prevention and control programs to improve employee and patient safety by: initiating and managing epidemiological investigations of significant clusters of infection or serious communicable disease concerns as a part of prevention, surveillance, and outbreak management; coordinating outbreak containment efforts within the area of focus; and consulting with Administration on infection control implications of architectural design, renovation, and construction.

+ Manages risk management efforts by: leading corrective action plan for areas of improvement identified through utilization review, clinical records audit, claim denials, patient satisfaction surveys, and auditing surveys across departments; empowering team members to complete root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches in order to identify areas of improvement and evaluate newly internalized processes and programs; requesting the completion of health outcome analysis to continuously monitor oversight effectiveness; and managing team members to escalate high-risk issues and trends to appropriate entity for resolutions.

+ Manages patient safety programs and initiatives by: coordinating the response to significant events of safety hazards, accidents, incidents, and threats through monitoring efforts and onsite evaluations; and collaborating with key stakeholders to develop patient care and satisfaction programs which aim to improve patient flow, clinical support, patient services, and seamless transition of care.

+ Provides consultation for the development of new clinical quality improvement programs by: consulting with teams and departments and developing relationships with departments, key stakeholders, and senior management to conduct needs analysis to develop new guidelines, metrics, and operational definitions of quality improvement through qualitative and quantitative program evaluation, analyzing program performance, performance reviews, and peer/department review groups; serving as a subject matter expert and leveraging a variety of health concepts, regulatory requirements, and change management principles to develop programs which optimize clinical quality, safety, or health outcomes; and ensuring continuous learning orientation are integrated into programs to assist with oversight, development, and improvement initiatives.

+ Manages the systems, procedures, and forms to improve data management programs and utilizes data to monitor and improve performance of all worker and patient safety programs by: ensuring the quality improvement monitoring agenda for assigned departments includes all aspects of data management and analysis of trends and patterns of practice; coaching team members on conducting statistical analysis for team members for conducting quality improvement evaluations; developing the procedures for gathering and entering data from databases, vital statistics, hospital patient discharge data, claims, and other relevant health sources; and analyzing and presenting reports (e.g., infection control research, utilization reviews, population health needs analysis, patient satisfaction) in specified formats for internal and external stakeholders, and working with departments to develop action plans.

+ Manages regulatory audits and survey efforts by: serving as the primary contact between external evaluators, vendors, and departments for onsite visits and evaluations; preparing ad hoc and complex requested audit documentation, information, reports, and tools throughout the auditing process; ensuring all practitioners complete required auditing surveys; and leading continuous survey readiness activities to maintain compliance with regulatory standards.

+ Manages the evaluation of the cost effectiveness, practicality, and appropriateness of medical care given to patients by: conducting routine case reviews with practitioners; empowering team members and practitioners to follow standard operating procedures for treatment for specific medical codes to ensure equal and timely access to care; overseeing current patient treatment plans to ensure patient needs are met in a timely manner and resolves issues; presenting findings of identified population health needs, such as community health concerns, access to transportation, knowledge of rights, reducing no shows, and others, and providing recommendations to senior leaders; and analyzing previous patient cases to identify areas of improvement for length of stay, type of treatment, and time of treatment, and reporting recommendations to the senior leaders.

Minimum Qualifications:

+ Minimum three (3) years of experience in a leadership role with or without direct reports.

+ Minimum three (3) years of experience with databases and spreadsheets.

+ Minimum three (3) years of experience delivering training programs.

+ Minimum three (3) years of experience in clinical setting, health care administration, or a directly related field.

+ Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum four (4) years of health care experience or a directly related field OR Minimum seven (7) years of experience in health care or a directly related field.

Additional Requirements:

+ Knowledge, Skills, and Abilities (KSAs): Negotiation; Risk Management; Compliance Management; Health Care Policy; Health Care Data Analytics; Learning Measurement; Community Health; Health Care Coding; Consulting; Managing Diverse Relationships; Delegation; Project Management; Risk Assessment; Health Care Quality Standards; Quality Improvement; Quality Assurance and Effectiveness; Evidence-Based Medicine Principles; Infection Control

COMPANY: KAISER

TITLE: Manager, Health Plan Quality Programs (Hedis and NCQA)

LOCATION: Honolulu, Hawaii

REQNUMBER: 1263845

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.