Manager, Care Management Quality

Job Locations US-MI-Southfield
Req No.
2018-2296
Category
Operations
Type
Regular Full-Time

Overview

ConcertoHealth Inc. is the leading provider of specialized primary care and supporting clinical services for complex, frail, elderly, and dual-eligible patients. Operating exclusively in value-based agreements, ConcertoHealth provides high-touch, individualized care for patients, and deploys wraparound clinical resources to extend the reach of primary care practices. This comprehensive medical management solution, elevated by Concerto’s proprietary population health technology, improves overall healthcare quality and patient outcomes, benefitting payers and their provider networks.

 

Concerto delivers comprehensive care to Medicare, Medicaid, and complex-needs patients. The Concerto name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. Our approach focuses on bringing harmony across the spectrum of a patient’s care, health, and dignity.

The company is headquartered in Irvine, Ca. For more information, please visit: www.concertohealth.com

 

JOB SUMMARY

The Manager, Care Management Quality will report directly to the AVP, Program Management, to develop and oversee standards of excellence in all aspects of care coordination performance and documentation quality as well as directly supporting a constant state of audit readiness for both internal and external partners/agencies. The Manager, Care Management Quality will be responsible for constructing and executing a comprehensive quality program, to include compliance with all NCQA standards.

Responsibilities

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Perform at the direction of the AVP, Program Management, to develop and oversee activities such as establishing care management standards of excellence including but not limited to design and implementation of audit tools, perform Inter-Rater Reliability (IRR) assessments, develop and monitor performance metrics in collaboration with CM leadership, and develop and implement the compliance tools needed for NCQA accreditation.
  • Develop and execute a comprehensive quality program, to incorporate client requirements and to include compliance with all NCQA standards and contractural obligations.
  • Collaborate with the Business Analysts (BAs) to ensure compliance with all NCQA reports and related requirements.
  • Work as a member of the leadership team and support company initiatives and keep executive leadership appraised of departmental issues
  • Recruit and hire qualified quality team members
  • Directly supervise quality team members, conduct all performance management functions
  • Drive the multi-disciplinary process of obtaining Case Management accreditation and maintaining ongoing re-accreditation with NCQA.
  • Acquire and maintain relevant clinical, technical, and information systems knowledge (TruCare, Patient 3D, etc.) and utilize such internal systems knowledge to develop and monitor programs and tools to ensure quality of care coordination performance and documentation
  • Design, deliver, evaluate and track quality performance and documentation in accordance with the regulatory standards for which the Company is contractually obligated (e.g. three-way contract between the State, CMS and health plan), accepted standards of care management and care coordination practices, the applicable Model(s) of Care, the delegated arrangement, company policies and procedures, and NCQA; including tracking and trending audit and monitoring results.
  • Establish a feedback mechanism to the managers of care management and the training function to ensure that remediation and performance management occurs in a timely fashion.
  • Escalate any concerns including, but not limited to, patient safety, clinical care risks, documentation, or compliance with regulatory requirements, to AVP, Program Management.
  • Establish oversight tools (audit and monitoring tools), policies, procedures and other process flows for quality monitoring and oversight of all care management team performance and system documentation with emphasis on timely and comprehensive care plan development and updates
  • In collaboration with the BAs, develop reports that assist and elevate tracking and trending of audit or monitoring results, and perform IRR related activities.
  • Present as a positive role model in promoting clinical care coordination excellence
  • Attend onsite visits and/ or meetings as needed or requested to assess current knowledge base and assist with remediation and performance improvement initiatives
  • Contribute to the development of guidelines, policies, and competencies
  • Maintain subject matter expertise in program requirements and Model of Care contracts
  • Provide guidance to staff for interpretation of program requirements and works collaboratively with executive leadership to develop business support tools for front-line
  • Deliver/ present individual or group training on care management execution standards of excellence, quality monitoring or audit findings in collaboration with training leadership and other care management leadership
  • Support the creation and maintenance of care management processes and procedures, systems workflows, training agendas and other supporting content using products such as Microsoft Visio, PowerPoint, and Excel as well as screen capture tools
  • Develop/ update new training content following policy and/ or procedure enhancements or clinical information systems/ applications upgrades as needed.
  • Interpret data gained though quality assurance process (i.e. training course evaluations) and making appropriate changes to maintain effectiveness.
  • Develop and maintain “super user” status for relevant care management team internal systems such as TruCare and Patient3D
  • Other duties as assigned

Qualifications

QUALIFICATIONS

  • RN or higher clinical licensure required
  • 5 years of experience as a practicing quality manager in a health plan, with oversight of the total quality program and staff
  • 3 years of experience with NCQA standards; including the successful completion of the Case Management accreditation processes
  • Bachelor’s degree strongly preferred
  • Must be able to travel to other sites where quality auditors are based to provide oversight and supervision (minimum 2 days visit per site)
  • Ability to work in a fast paced, dynamic environment and work well with others on a team
  • Demonstrate ability to perform multiple concurrent tasks with minimal supervision and meet deadlines
  • Demonstrate a sound understanding of contemporary healthcare with strong focus on clinical practice and clinical information systems/ applications
  • Proficiency in creating formal training materials and course documentation, including electronic learning development
  • Strong presentation skills and good verbal and written communication skills
  • Customer service oriented
  • Computer literate – proficiency in operating personal laptop, projector, learning management system, and other trainer tools
  • Proficient in Microsoft Office Suite
  • Experience training in medical facilities, exposure to medical office procedures is a plus
  • Proficiency in clinical information systems (i.e. electronic health records)
  • Excellent planning and organization skills
  • Possess a professional demeanor and appearance


COMPETENCIES

  • Strong Leadership Skills.
  • Organizing and Prioritizing.
  • Ability to collaborate across multi-functional teams and departments.
  • Excellent attention to detail and accuracy.
  • Confidentiality.
  • Judgment.
  • Verbal & written communication skills.
  • Information management skills
  • Problem-solving skills
  • Team work
  • Ability to meet deadlines

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