Quality Assurance Manager

Description

JOB SUMMARY: Under the direction of the Director of Redwood Coast PACE, develops, implements, and evaluates all activities of the Quality Improvement Plan (QIP). Acts as the compliance/HIPAA officer for Medicare Part D Fraud, Waste, and Abuse.

ESSENTIAL DUTIES & RESPONSIBILITIES:

1. Demonstrates respect for and promotes participant rights including dignity, self-determination, access to care, confidentiality, and independence.
2. Maintains confidentiality of all records and information.
3. Serves as a liaison among individual program disciplines, contracted hospitals, and community service providers on issues related to quality of care.
4. Coordinates with members of the Interdisciplinary Team (IDT) regarding quality of care and service delivery.
5. Designs, organizes, and implements the Redwood Coast PACE Compliance Program. Monitors and measures compliance issues, including conflicts of interest. Receives and documents reports of conflicts of interest and non-compliance.
6. In conjunction with the Director of Redwood Coast PACE, Assistant Director, and Center Managers, prepares and participates in Centers for Medicare & Medicaid Services (CMS) and Department of Health Care Services (DHCS) audits and develops corrective action plans.
7. Under the direction of the Director of Redwood Coast PACE, develops and updates policies and procedures.
8. Works with the Director of Redwood Coast PACE to ensure all program contractors and service providers are fully licensed and compliant with provider agreements, quality assurance, and participant rights policies and procedures.
9. Develops and monitors policies and procedures for quality oversight of contract services and provides related documents and information to contractors. Works closely with the Director of Redwood Coast PACE to receive, document, and resolve contractor incidents.
10. Conducts on-site review of contract organizations with delegated quality assurance programs, including medical groups, hospitals, and skilled nursing facilities. Coordinates credentialing of program health professionals.
11. Oversees the annual QIP update. Works closely with the Director of Redwood Coast PACE, Assistant Director, Center Managers, and IDT to identify standards, develop indictors, collects and analyzes data, and provides corrective action to improve performance.
12. Produces and interprets reports used in the QIP which may include reviews of medical records utilizing approved criteria. Prepares documents, reports, and/or medical record data for review by the Medical Advisory Committee (MAC), Quality Improvement Committee (QIC), and related subcommittees.
13. Coordinates quality assurance activities related to new enrollees as well as voluntary and involuntary dis-enrollment.
14. Evaluates and works to receive, document, and resolve medical and non-medical grievances and appeals by participants and/or their representatives (e.g. reports of participant rights violations, grievances, appeals, and other issues related to services and quality of care). Ensures information is reviewed for incorporating issues in development of the QIP.
15. Conducts focused and ad hoc quality studies and analysis shows. Identifies opportunities for improvement and facilitates annual Continuous Quality Improvement (CQI) projects.
16. Facilitates participant and caregiver satisfaction surveys every six (6) months as part of the Redwood Coast PACE QIP. Provides reports to the leadership team, QIC Committee, and Participant Advisory Committee (PAC).
17. Educates and assists Redwood Coast PACE employees regarding QIP initiatives. Collects aggregate information on participant care that is provided to the Medical Director/Primary Care Physician and MAC.
18. Ensures implementation of the Infection and Exposure Control plan, working collaboratively with Redwood Coast PACE medical professionals to ensure compliance of the plan.
19. Completes CMS quarterly reporting and participates in quarterly calls.
20. Completes bi-annual reporting for National PACE Association (NPA) and CalPACE.
21. Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to the Center Manager. Takes necessary measures to ensure a safe environment for others.
22. Serves as the Redwood Coast PACE Health Insurance Portability and Accountability Act (HIPAA) privacy officer under the direction of the MAC.
23. Supervises Medical Records Coordinator. Oversees requests for protected health information and ensures all requests for participant information have been approved by the participant and are HIPAA compliant.
24. Participates as a member of the Redwood Coast PACE leadership team and serves as the Redwood Coast PACE compliance officer.
25. Represents Redwood Coast PACE on the Humboldt Senior Resource Center’s agency Safety Committee and completes bi-annual Hazard Assessments.
26. Ensures that Redwood Coast PACE Incident Reports and fall assessments are completed and tracked for trends and compliance.
27. Participates in orientation with employees and contractors to ensure effective coordination of participant care.
28. Effectively collaborates with employees and contractors to meet Redwood Coast PACE goals and further success.
29. Complies with all policy and procedures of Redwood Coast PACE.
30. Acts in a manner consistent with agency values.
31. Other duties as assigned.

Qualifications

EDUCATION &/or EXPERIENCE:

1. Bachelor’s degree required, preferably in Nursing, Healthcare Administration, or another relevant field.
2. Two (2) years of experience working in quality assessment and performance improvement required, including professional experience administrating, aggregating, and analyzing data and survey results.
3. At least one (1) year of experience working with a frail or elderly population preferred.
4. Two (2) years of health care experience preferred.

LICENSES OR CERTIFICATES:

1. Valid California Driver’s License and personal auto liability insurance required. Must have a personal vehicle in good driving/operating condition, insured for State minimum liability requirements that can be used for the applicable job functions noted above.
2. Current CPR and First Aid certification within six (6) months of hire.

PRE-SCREENING REQUIREMENTS:

1. Requires clearance of a DOJ and FBI criminal history background check
2. Pre-employment physical and PPD skin test.
3. Requires Motor Vehicle Report verification.
4. COVID-19 and Influenza (flu) vaccines preferred.

JOB SKILLS:

1. Demonstrated experience in quality assurance and performance improvement activities.
2. Knowledge and experience working with the physical, social, and mental health programs operating within a licensed health facility or clinic.
3. Skills, knowledge, and abilities related to the health, mental, cognitive, and social needs of the participant population being served by the program.
4. Ability to coordinate, advocate, and cooperate with other agencies for seniors with tact and diplomacy.
5. Excellent written and verbal communication skills to convey information effectively. Ability to facilitate effective meetings.
6. Knowledge of safety and infection control requirements for healthcare facilities.
7. Ability to lead and manage projects, prioritize, and complete tasks effectively, adapting appropriately to changes in priorities and workload.
8. Data collection skills and knowledge of basic statistical principles. Ability to incorporate an understanding of detailed requirements in work activities.
9. Ability to collect, organize, and analyze data, administer surveys as well as create and maintain effective reporting.
10. Establishing and maintaining effective working relationships with others. Ability to maintain a positive attitude and build teams.
11. Sound verbal and written communication skills. Ability to communicate effectively and openly with other team members on participant’s status and needs.
12. Creative, detail-oriented, and organized. Ability to maintain accurate records.
13. Must possess integrity and practice discretion and objective problem solving.
14. Ability to use good judgment, resourcefulness, flexibility, and problem-solving skills.
15. Ability to function effectively within a multi-service, community-based nonprofit agency.
16. Ability to comply with program requirements and applicable government regulations.
17. Ability to speak to public and private community groups about agency programs and to participate in various outreach and fundraising efforts as required.
18. Strong basic computer skills (Microsoft Outlook, Word, Power Point, and Excel). Ability to navigate, use, and maintain database software programs. Basic knowledge of web-based applications such as timekeeping, training, and email programs.

SUPERVISORY REQUIREMENTS:

1. This position may supervise the following employees: IDT Coordinator.
2. In coordination with Human Resources and other supervisory staff, oversees hiring, orienting, training, evaluating, disciplining, and terminating of specified departmental staff.

PHYSICAL REQUIREMENTS:

1. Ability to sit at a desk and interact with a computer screen for extended periods of time.
2. Hand and arm strength sufficient to operate a keyboard for several hours each day.
3. Physical abilities sufficient to move between different staff work areas, communicate with co-workers and the public, operate a computer, produce reports, talk on the telephone, and travel to other agency worksites.

ANALYSIS OF PHYSICAL DEMANDS:

Key (Based on typical week): N=Never; R=Rarely (Less than 1 hour per week); O-Occasional (1%-33% of time); F=Frequent (34%-66% of time); C=Constant (over 66% of time)

The above statements are intended to describe the general nature of work performed. They are not to be considered an exhaustive list of all job tasks performed. The agency reserves the right to change job descriptions, work hours or work sites as required by the program.

The Humboldt Senior Resource Center is a private, non-profit, multi-purpose senior center providing a continuum of social and health related services. The agency currently holds contracts with the California Department of Aging and Area 1 Agency on Aging.

The Humboldt Senior Resource Center is an equal opportunity employer. We will not unlawfully discriminate against qualified applicants or employees with respect to any terms or conditions of employment based on race, color, national origin, ancestry, sex, sexual orientation, age, religion, physical or mental disability, medical condition, pregnancy, breastfeeding, gender identity, marital status, citizenship status, military or veteran status, genetic information, or other basis protected by applicable Federal or State law.

Salary : $68,640 - $75,000