Supervises

• Quality staff, including management staff.
• Develops operational objectives and plans; ensures the development and implementation of associated business plans and tactics to ensure compliance with relevant state and federal regulatory requirements for the Quality Program and NCQA accreditation requirements.

Essential Functions

• Anticipates the need for, and develops and implements relevant and effective quality management programs based on opportunities, issues and trends.

• Anticipates, identifies, analyzes and reports on quality opportunities, issues and trends; makes appropriate recommendations; develops and implements agreed upon changes.

• Assists Chief Medical Officer and Associate Medical Director in identifying medical service issues that have an impact on plan benefits and their administration; assists subordinate managers in resolving medical claims review, grievances, appeals, quality and other medical management issues.
• Collaborates with internal and external stakeholders to develop programs that increase awareness and provide educational opportunities to providers and members regarding HPSJ’s Quality Management program goals and activities.

• Conducts or oversees the preparation, implementation and corrective action plans for internal and external audit activities to ensure practices adhere to Milliman guidelines, NCQA requirements, regulatory guidelines and HPSJ criteria.
• Develops or oversees the development of relevant, timely and accurate internal and external Quality reports.
• Develops and manages department budgets; implements appropriate interventions.
• Develops, implements and maintains appropriate and required records, documents, policies and procedures. Collaborates with internal and external stakeholders to ensure the collection, storage and retrieval of relevant data and information.
• Leads and Oversights NCQA accreditation activities to ensure ongoing compliance.
• Oversees the HEDIS process of monitoring, reporting and implementation of interventions for improvement.
• Oversees the credentialing and peer review process.
• Collaborates with medical management and other departments to ensure that the Quality program meets or exceeds NCQA and regulatory standards.
• Promotes and maintains, and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values.
• Hires, develops and retains, and ensures that subordinate managers hire, develop and retain, a competent staff.

• Strong clinical skills.
• Very strong knowledge of NCQA standards and their application to quality and disease management.
• In-depth knowledge of and proficient skills in administering protocols for quality management.
• In-depth knowledge of regulatory requirements pertaining to quality management and credentialing.
• In-depth knowledge of standard contract components and contract language specific to healthcare.
• Strong knowledge of medical management information systems and their interrelationships.
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.
• Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results.
• Ability to develop and manage realistic budgets.
• Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
• Decision quality: Makes good and timely decisions that keep the organization moving forward.

• Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.
• Ability to translate strategic concepts into actionable business plans.
• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.

• Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.
• Ensures accountability: Holds self and others accountable to meet commitments.
• Drives results: Consistently achieves results, even under tough circumstances.
• Very strong interpersonal skills with the ability to initiate establish and maintain effective working relationships with diverse individuals both inside and outside of HPSJ.
• Very strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of HPSJ; includes the ability to effectively explain complex information.
• Very strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
• Very strong collaboration skills with demonstrated ability to create and foster a collaborative work environments.
• Strong project management skills, including the ability to manage organizational-wide projects to successful conclusion.
• Builds networks: Effectively builds formal and informal relationship networks inside and outside of the organization.
• Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.
• Persuades: Uses compelling arguments to gain the support and commitment of others.
• Manages ambiguity: Operates effectively, even when things are not certain or the way forward is not clear.
• Strong knowledge of change management theory, with ability to anticipate and implement effectively.
• Strong customer service skills.
• Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
• Ability to supervise staff, and ensure that direct reports supervise staff, in a manner that maximizes employee performance and business results; includes very strong coaching/counseling skills, including the ability to function as a mentor to management and employees.
• Intermediate mathematics skills, including basic algebra.
• Intermediate skills in Word, Excel and Outlook, including the ability to develop spreadsheets, formulas, and create tables and graphs.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

• Knowledge of the principles and practices of managed care.
• Knowledge of managed healthcare as applied to government sponsored programs including Medicaid and Medicare.
• Knowledge of managed care systems in a Knox-Keene licensed HMO.

• Graduation from an accredited nursing school; and
• Bachelor’s Degree in nursing, business management or related fields; and
• At least five years in quality management and/or disease management in a healthcare setting; and
• At least five years supervisory experience in a healthcare setting; or
• Equivalent combination of education and experience.

• Master’s Degree in Nursing.
• Experience in an HMO or managed care setting.
• Experience in QM for government sponsored programs.

• Current unrestricted California RN license.
• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.

• Competitive salary
• Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• Leadership Development Program
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.