Shire Jobs

This job was posted by https://idahoworks.gov : For more information, please see: https://idahoworks.gov/jobs/2262594 Manager, Clinical Quality Management & Compliance

Work from home within Oregon, Washington, Idaho or Utah

Build a career with purpose. Join our

Cause

to create a person-focused and economically sustainable health care system.

Who We Are Looking For:

Every day, Cambia\'s dedicated team of Transformation, Quality, & Learning leaders are living our mission to make health care easier and lives better. As a member of the Transformation, Quality, & Learning team, our Manager Clinical Quality Management & Compliance directs and manages the activities of a clinical quality programs team. This position oversees staff and provides leadership and direction to ensure operational and procedural compliance with regulatory requirements for Health Care Services in addition to maintaining enterprise-wide accreditation. The Manager Clinical Quality Management & Compliance represents the department in interactions with all levels of management, vendor partners, providers and outside consultants. - all in service of creating a person-focused health care experience. As a people leader, you are willing to learn and grow, understanding that leadership is a craft that is continuously honed as you support your team and the lives that depend upon us.

Are you a seasoned healthcare professional with a passion for ensuring exceptional clinical quality and regulatory compliance? Do you have a knack for leadership and a talent for driving operational excellence? Then this role may be the perfect fit.

What You Bring to Cambia:

Qualifications:

• Bachelor\'s degree in a related field required (e.g., healthcare administration, healthcare policy, nursing, pharmacy, industrial engineering) Masters degree in related field preferred.
• 5+ years in a quality management, internal audit/compliance, or process consulting role in a highly regulated industry (e.g., healthcare, finance, power).
• 3+ years of working in managed care health insurance industry. Utilization management experience required.
• Training or certification in quality improvement (e.g., CQM, CQA, Lean Six Sigma, ISO).
• Knowledge base of clinical standards of care, medical policy, coding, NCQA, CMS and other relevant state regulatory agency requirements.

Skills and Attributes:

• Excellent analytical skills with the ability to assess complex business processes and data sets.
• Strong program management skills with demonstrated ability to focus activities aligned with strategic priorities and to develop tactical plans, drive performance and achieve targets.
• Demonstrated knowledge of healthcare insurance industry products (e.g. Medicare Advantage, Commercial, ASO, ACA).
• Demonstrated knowledge of applicable locations of care (e.g., rehab, SNF, home care, and home and community bases services, etc.).
• Excellent communication and presentation, time management, organizational, and prioritization skills.
• Proven leadership skills with ability to motivate teams and facilitate large-scale change.
• Detail oriented and organized with sound judgment, integrity, and ethical decision-making skills.

What You Will Do at Cambia:

Develop and oversee an effective clinical quality management/assurance program, including quality management strategies, policies, monitoring and reporting.

Analyze performance compared to internal and external benchmarks to identify opportunities for improvement.

Monitor all internal and delegated operations and related metrics for conformance with internal, external, contract performance, and quality standards.

Collaborate with stakeholders to identify and mitigate risks, error-proof systems, and uphold compliance standards.

Develop an ef ective quality assurance function including audits of systems, work processes, clinical determination and member engagement to identify opportunities to improve compliance and/or narrow unwarranted variation.

Plan and execute risk-based testing of key controls and processes to evaluate operating effectiveness against NCQA, CMS, state and contract requirements, as well as key business processes.

Oversee internal and vendor audit functions to assure a modernized audit function that produces thorough and objective audits.

Partner with shared services to implement improvements through workflow processes, training, and/or technical improvements to improve overall performance.

Collaborate with external auditors, regulatory agencies, and other stakeholders as needed to facilitate external audits and regulatory inspections.

Extract, aggregate, and analyze data to identify trends and opportunities for improvement.

Present findings and recommendations to management, committees, and external stakeholders.

Oversee process to track, monitor, and report on Corrective Action Plans.

Develop, update, and/or review policie