| Department: |
Network Management
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| Level: |
Supervisory
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| Reports To: |
Director, Network Management
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| Private Health Information (PHI): |
Position requires access to PHI, including "read only" access to eligibility, claims and authorizations. "Write" access to member notes and provider notes.
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| Job Classification: |
Exempt
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| Job Type: |
Full time - Four-Day 10 hour days, Monday - Thursday |
| Pay Rate: |
Salary is based on qualifications and experience |
| Position Summary: |
Provide leadership and operational management for quality and risk programs across the provider network. Supervises the daily activities of the performance team. Develops and implements quality improvement initiatives. Collaborates with internal departments and health plans to ensure compliance with IHA, HEDIS and CMS Stars initiatives. Responsible for annual quality data reporting and the audit process. Oversees the annual assessment program to ensure accurate documentation.
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| Essential Job Functions: |
Reporting – Monitor IPA performance and staff productivity. Analyze data to measure program effectiveness.
Programs – Develop and monitor initiatives for ongoing IPA improvement. Create tools and materials for training and performance monitoring.
Client Relations – Works with the Director of Network Management to maintain positive and productive relationships between department staff, health plans, providers and members. Works with Provider Relations team to communicate with physicians and their staff. Meet with physicians as needed.
Staff Supervision – Supervises the daily activities of the performance staff, employee work schedules and work assignment to ensure effective business operations. Takes appropriate corrective action when required to improve employee performance in accordance with policy. Participates in the interviewing and hiring of new staff. Provides staff training as required.
Represents the MSO in state/regional meetings and conferences specific to quality. Including but not limited to IHA, health plans, IPA meetings, vendor user conferences.
Performs other duties as assigned.
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| Position Qualifications and Requirements: |
Prior supervisory experience managing diverse areas of responsibility. Minimum of 3 years of operations experience in a health plan, MSO or medical group environment and have a working knowledge of managed care principles.
Prior Quality Improvement experience. Knowledge of regulatory requirements related to quality programs including NCQA’s HEDIS, Medicare STARS and the Integrated Healthcare Assoc. AMP program.
Strong customer service and professional communication skills, both written and verbal, required.
Excellent organizational and time management skills. Ability to work on multiple complex projects simultaneously.
Advanced knowledge of Microsoft Word, Excel, email and intermediate knowledge of PowerPoint, Access and other applications/information system pertinent to managing data and conducting training sessions. Experience in data analysis.
Familiar with claims processes, CPT, ICD-10 and HCPCS coding desired. Certificate in coding is a plus
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| Education/Course(s) /Training: |
Bachelor’s Degree in health care administration, public health, nursing, or other related field or equivalent work experience required.
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| Licensure/Certification: |
Reliable transportation, a valid CA Driver’s License, and current car insurance meeting CA standards.
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Location: |
Mira Mesa, San Diego |
| Date Posted: |
January 26, 2023 |
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To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org |
