QI Manager, Louisville, KY Area
Location: Louisville Kentucky
Description: CareSource is employing QI Manager, Louisville, KY Area right now, this position will be placed in Kentucky. For complete informations about this position opportunity please read the description below. Job Summary: The Manager Quality Improvement is responsible for oversight of clinical appeals, state and administrative hearings, and Independent External Reviews for health plan! while ensuring compliance with all Federal, State, and Accreditation requirements. Is responsible for oversight of the HEDIS Medical Record Review Unit for health plan and chairs the CareSource Clinical Initiative Workgroup. Oversees the Clinical Appeals Team and Quality Improvement Specialists in conjunction with the QI Director. Ensures compliance with External Quality Review studies, Performance Improvement Projects, and Quality Improvement Projects required by the State of Ohio, URAC, and other accreditation bodies. Essential Functions: • Directs the day-to-day prioritization of staff activities in collaboration with the Director Quality Improvement • Responsible for the Corporate oversight of clinical appeals, state and administrative hearings, and Independent External Reviews for all health plans • Responsible for Corporate oversight of the HEDIS Medical Record Review Unit • Chairs the Corporate Clinical Initiative Workgroup that is responsible for the develo! pment and implementation of HEDIS clinical initiatives and all! other assigned clinical initiatives • Responsible for oversight of Quality Improvement Projects and Performance Improvement Projects related to accreditation and State of Ohio requirements. in conjunction with other departments • Ensures Caresource compliance with External Quality Review studies, Performance Improvement Projects, and Quality Improvement Projects required by the State of Ohio, URAC, and other accreditation bodies • Responsible for the review of QI issues and grievances related to quality of care in compliance with Federal, State, and Accreditation requirements • Oversees annual and quarterly audits of QI cases, QI database integrity, and aggregate reporting accuracy • Ensures all policies and procedures are aligned with Federal, State, and Accreditation requirements • Responsible for the annual review and update of QI Department policies and procedures within the Compliance 360 module • Provides education to internal and external customers on ! quality improvement functions • Responds to questions that pertain to appeals, HEDIS, and Quality Improvement from providers and internal staff member • Foster relationships with all internal departments and represent CareSource to community-based programs • Performs other job related instructions as requested, with reasonable accommodation.
Position Requirements
Minimum Qualifications: Education: • Current, unrestricted Registered Nurse (RN) licensure in the state of practice required • BSN • Masters degree preferred Experience: • Three or more years in a MCO; Medicaid experience preferred • Experience in quality required • Experience with accreditation required Certification: • MSN or BSN or other degree in medical related field preferred Technical Skills: • Data analysis and trending skills • Proficiency in Microsoft Word, Excel and PowerPoint • Intermediate computer skills Knowledge & Skills • Communication skills •! Prior supervisory skills • Ability to work independently and within ! a team environment • Attention to detail • Familiarity of the healthcare field • Knowledge of Medicaid • Critical listening and thinking skills • Training/teaching skills • Strategic management skills • Proper grammar usage • Technical writing skills • Time management skills • Proper phone etiquette • Customer service oriented • Decision making/problem solving skills • Leadership experience and skills
Educational Requirements
Education: • Current, unrestricted Registered Nurse (RN) licensure in the state of practice required • BSN • Masters degree preferred
License Requirements
Certification: • MSN or BSN or other degree in medical related field preferred • Current, unrestricted Registered Nurse (RN) licensure in the state of practice required
Full-Time/Part-Time
Full-Time
Shift
Days
Salary
M07 $71,126/Annual Min
About the Organization
Ca! reSource is the 2nd largest Medicaid managed health care plan in the country, and our strength lies in our experience. CareSource provides a full spectrum of services for the administration of public-sector health care programs, serving more than 900,000 Medicaid consumers in Ohio and Michigan.
Our health plans are founded on the principles of quality and service delivered with compassion and a thorough understanding of Medicaid, Medicare, and the associated regulatory environments. We offer a unique approach to managed care through the process efficiencies and value-added benefits we offer to our members and the health care providers we partner with to serve them. As a managed health care organization, CareSource focuses on prevention with a goal of improving member health and the quality and accessibility of health care services for Medicaid consumers. CareSource assists in the coordination of member care by partnering with a defined network of participating doctors, ! hospitals and other health care providers.
CareSource Benefits
! CareSource is an equal opportunity employer that offers a drug and tobacco free environment and a competitive compensation and benefits package to full-time and part-time employees who work at least 24 hours per week.
The benefits package includes:
- Health, dental and vision insurance
- Flexible spending accounts (health and dependent care)
- Life insurance
- Accidental death and dismemberment insurance
- Short- and long-term disability insurance
- 401(k) retirement plan
- Liberal paid personal time to be used on a discretionary basis for sick leave or as scheduled time off
- Eight paid holidays and a floating holiday
- Educational reimbursement
- .
If you were eligible to this position, please email us your resume, with salary requirements and a resume to CareSource.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Mon, 21 Oct 2013 08:12:07 GMT
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