Director, Clinical Service Progrms/Quality Management - Medical

Description DIRECTOR, CLINICAL SERVICE PROGRAMS/QUALITY MANAGEMENT: Provides leadership and coordination of all aspects of the Clinical Service Programs and Quality Management departments. RESPONSIBILITIES: •Provide training, coordination and direction for the day-to-day functions. •Supervisory responsibility for 8-11 employees. •Oversees compliance with confidentiality of all clinical information collected or viewed. •Develop, implement & monitor outcomes measures for training programs. •Collect, report, analyze and trend performance standards for departmental performance reports. •Develop, implement and monitor polices and procedures for medical management contracts and accreditation compliance. •Consult with Medical Director in program development. •Conduct presentations to potential clients for medical management services. •Prepare departmental budget. • Interpret regulations, policies, operational procedures, and objectives, to ensure that the highest level of quality is consistent with Corporate standards. •Provide clinical and operational oversight of each medical management initiative which include utilization management, case management, disease management, a 24/7 nurse triage line as well as an analytical function of clinical data to drive each initiative. •Oversee nurses credentialing process and HIPPA compliance for the Medical Management Department. •Actively coordinate and effectively communicate Quality Management and Process Improvement activities throughout internal environment and external delivery system. •Facilitate compliance with state, federal and local laws and regulations regarding Quality Management and accreditation requirements. •Coordinate annually the development of the key Quality Management Program Documents, Quality Management Program Description, Quality Management Work Plan and Quality Management Program Evaluation. •Assist in the development, communication and implementation of the Medical Director’s and QM committee’s decisions and/or corrective action plans. •Develop and oversee the production and presentation of monthly, quarterly and annual QM reports. •Identify opportunities to improve clinical care, customer service and internal business processed. •Develop, review and analyze member and provider satisfaction surveys and identify opportunities for improvement. • Develop and oversee the performance, analysis and reporting of audit, focused study and survey activities. •Coordinate and perform quality of care investigations, including preparing cases for Medical Director and Peer Review Committee. •Oversee the complaints and grievance process, track and trend data and coordinates reporting per program requirements.

Requirements •Bachelor’s degree in a health related field required. •Florida Registered Nurse license or Risk Manager designation is preferred. •Minimum 5 years of managed care experience at the Director Level required. •URAC & NCQA accreditation required. •Utilization Management experience required. •Case Management experience required. •Disease Management experience required. •HEDIS experience highly preferred. •Proven ability to develop and implement medical management programs. •Thorough knowledge of HIPPA regulations. •CPHQ preferred. •LHCRM preferred. •Proven ability to create the written records and presentations necessary to document compliance with applicable laws, regulations and external oversight of organization standards. •Certified Case Management (CCM) Certification is preferred, other certifications recognized by URAC are also acceptable. •Proficiency using word processing, spreadsheet and database software.