Mgr Clinical Quality-19279

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.



This position will oversee functional areas within the State Sponsored Business Quality Management Department in the mid-west region. Requires management of the Mid-West Quality Management Department, Quality Management committees and associated projects/processes simultaneously. Coordinates these processes with the required Quality Management committees, credentialing, network services, field staff and regulatory entities. Audits and revises policies and procedures pertaining to facility site reviews, medical records, sentinel events, and internal quality improvement projects, ensuring compliance with NCQA, contract and regulatory requirements. Manages staff to monitor and maintain performance and standards in the areas of facility site reviews and medical record reviews for all states/contracts. Also provides clinical oversight to field QM nurses, coordinates field activities related to facility site reviews and HEDIS data collection. Ensures fair and appropriate resolution of member/provider issues. Participates in development of department metrics including analysis and communication of results through various distribution channels.

Requires Current RN license.BSN required, Master's preferred. Requires 3-5 years managing direct reqports.   Prefers 3-5 years managed care experience.  Experience in program development and knowledge of the quality process and QI techniques required. Proficiency with PC and excellent written and verbal communication skills and evidence of ability to perform program assessment and to evaluate opportunities for improvement also required.