The regulatory function is vital in making safe and effective healthcare products available worldwide. Individuals who ensure regulatory compliance and prepare submissions, as well as those whose main job function is clinical affairs or quality assurance are all considered regulatory professionals.
One of our most valuable contributions to the profession is the Regulatory Code of Ethics. The Code of Ethics provides regulatory professionals with core values that hold them to the highest standards of professional conduct.
Like all professions, regulatory is based on a shared set of competencies. The Regulatory Competency Framework describes the essential elements of what is required of regulatory professionals at four major career and professional levels.
Join the brightest minds in regulatory at the annual Regulatory Convergence. See the global regulatory community in action. Intensive workshops. Topical sessions. Meet ups with regulators. This is where it all comes together.
Our Mission…Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system
We are looking for fun, intelligent, team oriented people who believe in our core values: Trust, Respect and Integrity.
Under the direction of the Director of QI, the QI Manager conducts oversight and management of state and regulatory and contractual compliance for the QI program. This includes managing the HEDIS and Managed Care Accountability Set (MCAS) audit and initiatives to improve health outcomes related to those measures. They also manage quality improvement initiatives for Performance Improvement Projects (PIPs), Improvement Plans (IPs), Facility Site Reviews (FSRs), delegation audits, and other external quality reviews. The manager applies clinical knowledge and analytical skills to manage and oversee day-to-day operations of the QI team in support of improving performance metrics of organizational goals.
The QI Manager is responsible for supervising the QI team for a Knox-Keene licensed health maintenance organization (HMO). The manager has advanced knowledge of health care delivery systems and State and Federal regulatory requirements, including but not limited to those from the DMHC, DHCS, and CMS. Responsibilities include oversight of all FSRs, Grievances and Potential Quality Issues, including grievance committee participation and quality of care reviews for the organization. The manager manages the annual audit process for HEDIS/MCAS. They also oversee all performance improvement activities and submissions required by our regulatory agencies.
MAJOR DUTIES & RESPONSIBILITIES
In coordination with the Director of QI, develops, implements, and maintains a standardized quality management workplan and program description to ensure compliance with external regulatory and requirements.
Establishes and maintains tracking and monitoring systems for health care quality improvement activities according to regulatory requirements, policies and procedures, and contractual agreements.
Ensures high risk, high volume, and unusual events are monitored concurrently and retrospectively as they occur.
Researches and documents current health care standards for use in performance improvement study design and methodologies related to health outcomes. Provides assistance, guidance, and oversight to clinical staff with regard to study design, methodology, data analysis and reporting.
Manages and evaluates performance of QI department staff. Establishes an orientation program for new QI Department staff. Provides department orientation and leverages other appropriate staff to provide aspects of orientation to new staff. Develops ongoing staff development to the entire department.
Coordinates guidelines, studies and performance improvement activities in concert with the utilization management, quality management, pharmacy services, case management and disease management programs.
Maintains a knowledge base of HEDIS/MCAS requirements and participates in planning and implementation of methods to improve HEDIS/MCAS performance.
Prepares, compiles, reviews and submits monthly and quarterly reports for the Quality/UM Committee, Compliance Committee meetings, and Department monthly report.
Participates in the development, review and updating of policies and procedures.
Develops the annual Plan Quality Program Evaluation and updates the QI Program Description and Workplan in coordination with the Director of QI.
Coordinates the regular and systematic review of all potential quality of care issues in accordance with state statute.
Develops and analyzes reports to monitor and evaluate quality performance in meeting established goals related to the QI work plan and contractual requirements.
Monitors productivity of department staff and establishes productivity minimum expectations for each role. Provides regular feedback and support to staff in meeting performance expectations.
CORE COMPETENCIES/KNOWLEDGE & SKILL REQUIREMENTS
Knowledge of and skill in protocols of Quality Improvement;
Strong knowledge of common patient disease processes and usual methods of treating them ;
Thorough knowledge of medical terminology and commonly used equipment ;
Ability to effectively evaluate medical records for appropriateness of care ;
Ability to assess and judge the clinical performance of physicians and other health professionals ;
Strong analytical, assessment and problem-solving skills ;
Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of KHS ;
Facilitates an atmosphere of collaboration and team work ;
Ability to effectively manage both clinical and non-clinical staff in support of both individual staff and team success ;
Ability to use tact and diplomacy to diffuse emotional situations ;
Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards ;
Intermediate skills in Word, PowerPoint, Excel, and Outlook with basic ability to enter data into and navigate through a database ;
Maintains confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information ;
Self-directed and able to work independently. Uses appropriate judgment to seek assistance and ask questions ;
Keeps Director of QI updated on overall activities, issues identified, and actions to address issues ;
Operates with target dates and deadlines and is able to meet deadlines with successful outcomes. Appropriately negotiates changes to target dates and holds staff accountable similarly to target dates ;
Strong attention to detail and work accuracy ;
EDUCATION, EXPERIENCE, AND TRAINING REQUIRED
Associates Degree in Nursing required; Bachelor’s Degree in Nursing, Health Administration or other healthcare field preferred, and five (5) years of experience in the direct patient care setting,and one (1) year of experience in health care Quality Improvement or Utilization Management, and two (2) years of management experience;
Working knowledge of HEDIS measures and the HEDIS audit process:
Working knowledge of State and Federal regulatory requirements, particularly related to QI activities;
Registered nurse with an active license in good standing with the State of California;
Certified Professional in Healthcare Quality (CPHQ) preferred ;
Possess a valid California Drivers License with transportation and automobile liability insurance limits acceptable to KHS. Up to 25% driving.
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.
Employer will assist with relocation costs.
Additional Salary Information: Benefits to include, Medical, Dental, Vision, Retirement and much more..
Internal Number: 1442
About Kern Health Systems
Kern Health Systems, known as Kern Family Health Care, was established in 1993 as a managed care health plan, and is the largest health plan in Kern County. Kern Health Systems is committed to providing quality health care to our members. It is important to ensure good health through continuity of care by connecting each member to a provider of their choice within our provider network. Our extensive provider network includes the Traditional and Safety-Net Providers that historically delivered care to Medi-Cal recipients and private providers throughout Kern County and some parts of Los Angeles County.
We believe good patient/physician relationships and effective preventive care are true indicators of our success. We also offer a continuum of care that extends beyond doctor visits. With a full range of health education classes and Care/Disease Management programs, we provide quality educational and preventive services to the population we serve. We are able to achieve this through partnerships with our providers and community-based organizations within Kern County. The difference is clear: We hold the standard high when it comes to quality health care for our members.
Our Mission… Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system. As Kern Health Systems continues to move forward, we will continue to uphold our mission of being dedicated to improving the health status of our members through an integrated managed healthcare delivery system. As the healthcare landscape has been transformed, we will pursue tomorrow with community and provider innovation, enhanced member access, and strengthened member health and wellbeing...Together.