The QualityManager position is designed to provide, manage, and document continuousactivities that identify, evaluates, and improves the quality and safety ofcare and services provided to all Seaside Health Plan members. This individual will also be responsible for the ongoingmonitoring and analysis of organizational performance, to assist in the designand implementation of quality improvement initiatives in support of thestrategic objectives of the organization.
Essential Functions and Responsibilities of the Job
Responsible for the operational execution ofthe QM Program under the direction of the Director of Medical Management andChief Medical Officer
Responsible for the development,implementation and evaluation of the QM Program and Work Plan.
Responsible for the operations of all QMactivities for Seaside Health Plan, including monitoring and reporting asrequired by regulation or contract.
Responsible for management of the QMstaff, which includes a Health Educator, QA Coordinator, and CredentialingCoordinator
Develops P&Ps, workflows and requireddocuments to meet federal and state regulatory requirements, as needed in focusarea
Organizes and maintains filing systems andarchival records
Oversees health promotion and qualityinitiatives
Reviews medical records to determine completenessand accuracy of potential quality of care issues for further action andinvestigation according to specific process
Educate primary care providers on clinical andpreventative health guidelines, documentation standards, and coding for outcomereporting
Oversees the credentialing processto ascertain that Seaside's contracted Providers areproperly trained, licensed and certified to provide safe, competent care tomembers
Distributes gap reports and educationalmaterials to providers
Communicates effectively with aprofessional attitude.
Ability to be at work and be ontime.
Follows company policies,procedures and directives.
Responsible for the operational execution of theQM Program
Responsible for the development, implementationand evaluation of the QM Work Plan
Responsible for the management of staff assignedto QM activities for Seaside Health Plan, including monitoring and reporting asrequired by regulation or contract
Oversees regulatory compliance as it pertains toquality and safety
Acts as educator and resource to all departmentsin matters of health care quality
Responsible for review, updates, and developmentof Seaside Health Plan Quality P&Ps
Identifies, reviews, analyzes, and tracks PQIs,sentinel events, and unintended outcomes
Reports QM activities to the Quality Council
Oversees elements of Health Education Program
Manages and provides support for the CredentialingCoordinator