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MLTC Quality Control Manager at MetroPlus Health Plan

MLTC Quality Control Manager

MetroPlus Health Plan New York, NY Full-Time
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Marketing Statement

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

The Quality Control (QC) Manager of MLTC is responsible for supporting the day-to-day functions of the MLTC Plan. He/she will manage MLTC’s quality control & quality improvement activities and initiatives, including overseeing the MLTC Quality Analyst. He/she will analyze performance and recommend improvement initiatives and/or corrective actions strategies. The QC Manager will oversee the quality of assessments, care plans and the care planning processes. The Quality Control Manager will be responsible for developing, implementing, and evaluating MetroPlus’ MLTC performance improvement activities including, but not limited to, analyzing data to identify performance trends; prioritizing and recommending improvements and coaching staff to achieve better performance. The QC Manager will play a role in ensuring compliance with all State and Federal contractual requirements regarding quality management.

The QC Manager will anticipate and resolve complex issues and ensure accurate and quality record keeping. The QC Manager will work closely with the Medical Management Quality Management department as well to ensure that QM staff have access to the MLTC records and information they need.   In addition to the day-to-day responsibilities, the Quality Control Manager will work in conjunction with the Director of MLTC-PCS on a variety of critical tasks.



Job Description

  • Responsible for creating the business processes to ensure high quality and timely assessments and care plans
  • Oversee the MLTC Analyst who will report to the QC Manager
  • Responsible for identifying opportunities for performance improvement in both clinical and operational areas e.g., preventing falls, reducing readmissions, ensuring timely delivery of DME
  • Manage the annual MLTC performance improvement project (PIP) including project focus, metrics development, tracking, and reporting.
  • Work with IPRO to ensure timely reviews of interim and year-end reports
  • Develop and implement on-going staff trainings necessary for improving the timeliness and accuracy of assessment, tasking tools, and care plans
  • Oversee the implementation of corrective actions related to internal and external audit findings
  • Identifying data resource needs and work with other departments (e.g., IT, Analytics, QM) to provide visibility for tracking and monitoring purposes
  • Use the principles of continuous quality and performance improvement to monitor functions and drive organizational improvements in processes.
  • Perform periodic performance reviews and targeted audits as determined by the leadership and performance trends.
  • Work with Regulatory and compliance to resolve and respond to NYSDOH complaints. 
  • Work with Quality Management to coordinate member outreach efforts to align resourcing and avoid duplication
  • Follow-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents and NYSDOH complaints were implemented effectively. 
  • Regularly conducts audits of patient/member case records, and shares findings with team leads and staff members
  • Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology. 
  • Keeps informed of the latest internal and external issues and trends in utilization and quality management. 
  • Develop standards of staff performance and oversight to ensure performance indicator’s and program requirements are being met.
  • Prepare data and written reports or materials for meetings and as required or requested by leadership.
  • Evaluates and assesses staff on an on-going basis, offering oral and written counseling as deemed required. 
  • Conducts departmental meetings and in-services associated with the implementation of new policies and procedures specific to MLTC.  
  • Performs other duties as directed and as necessary.


Minimum Qualifications

  • Registered Nurse with a current licensure in NYS. Bachelor’s Degree required. 
  • A minimum of three years experience in a MCO setting, preferably with MLTC
  • Minimum of three years managerial experience.  
  • Excellent communication, written and analytical skills.
  • Knowledge of computers and healthcare information systems.
  • Highly organized skills required.
  • Ability to work in a fast pace environments and technical clinical expertise required.

Preferred Qualifications

  • Experience with geriatric population 
  • Certification in Case Management
  • Knowledge and expertise of care management-based computer systems and Microsoft office products.
  • Experience with Medicaid recipients and community services
  • Experience in managed care and/or care management 

Licensure and/or Certification Required

  • Registered Nurse with a current licensure in NYS

Professional Competencies

  • Integrity and Trust
  • Customer Service Focus
  • Functional/Technical skills 
  • Written/Oral Communications
 

Recommended skills

Product Quality Assurance
Medicaid
Analysis
Managed Care
Communication
Leadership
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Job ID: PGM-CC-6907_56160

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