Supervisor, Quality Assurance

SUMMARY:  The Manager, Quality Assurance will be responsible for putting together and maintaining a production, audit and training program for the Clinical Services Department.  The program will included reporting on workflow management, department/staff production, audit reporting and inventory management.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES include, but are not limited to, the following:

 Acts as a department resource and provides guidance/support to staff members.

 Performs routine and moderately complex audits on paper and electronic authorizations to identify inaccurate adjudication.  Will run and audit exception audit reports on a daily basis.

 Tracks quality of authorization and/or case processing and logs data. Communicates results of audit process to Clinical Services Department management in order to improve processing accuracy.  Participates in weekly team conferences with the Medical Director.

 Identifies productivity metrics for all service lines contained in the Clinical Services Department. Develops weekly and monthly standard progress reports on department workflows and quality metrics.

 Develops monthly staff audits and random case reviews, and provides regular feedback to staff on work products.  Integrates findings into regular trainings as well as employee files.

 Maintains records of training activities and employee progress, evaluates effectiveness of program and incorporates enhancements as required. Develops ongoing training program for staff as well as internal levels of certification for staff that achieve thresholds of performance and training. Provides qualified data for incorporation into training programs, policies and procedures. 

 Confers with management to assess training needs in response to changes in policies, procedures, regulations and technologies. Determines appropriate instructional methods and designs programs and materials.  Conducts training sessions covering authorizations and/or case processing to ensure quality.

 Revises and oversees operational process documentation and links to departmental policies.  Operational processes should be made available to staff as well as external entities.

 Summarizes findings and recommendations in reports for feedback to examiners and distributes results to management.  Assists management with their evaluation of controls and acts as a consultant to suggest ways to resolve problem issues.

 Oversees all health plan audits and external validations as necessary at the direction of the Director of Clinical Services.

 Oversees the credentialing process and integrates performance improvement findings into credentialing process. Coordinates materials and information for Quality and Credentialing committees.

 Generates annual QI work plan, quarterly reports and annual QI program evaluations.

 Other duties as assigned.

 

 

QUALIFICATIONS/REQUIREMENTS:

 

  EDUCATION and/or EXPERIENCE:

Bachelor?s degree in a healthcare discipline with 2-3 years quality monitoring/improvement experience in a healthcare organization; medical management/authorization experience in an IPA, medical group or HMO preferred; 2-3 years disease management experience preferred; or equivalent combination of education and experience. Thorough knowledge of Microsoft Word, Excel and Access.  Skills should include service orientation, excellent oral and written communication, problem solving, negotiation, diplomacy, health promotion and training. 

 

LANGUAGE SKILLS:

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.  Ability to effectively present information to management, physician committees, public groups, and/or boards of directors.

 

MATHEMATICAL SKILLS:

Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

 

REASONING ABILITY:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

 

OTHER SKILLS AND ABILITIES:

  Microsoft Office knowledge required.

 

PHYSICAL DEMANDS:  The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; and talk or hear.  The employee frequently is required to sit.  The employee is occasionally required to stand and walk.

 

The employee must occasionally lift and/or move up to 25 pounds.  Specific vision abilities required by this job include close vision.

 

WORK ENVIRONMENT:  The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

The noise level in the work environment is usually moderate.