Job Description

Location: US Family Health Plan
Posted Date: 9/10/2020

POSITION SUMMARY:

The Manager of Quality and Performance Improvement (QPI) is responsible for the development, implementation and oversight of all quality management activities for the US Family Health Plan. The Quality and Performance Improvement Manager, in collaboration with the Senior VP and Executive Director, manages the USFHP Compliance Program including compliance with all applicable Tricare regulations and additional obligations as outlined in the Department of Defense (DoD) contract.

As the senior quality leader for US Family Health Plan, the position provides stewardship for quality projects chartered by the Health Plan. The QPI Manager leads the USFHP Quality Management Committee (QMC) and recommends population health and disease management initiatives in collaboration with the Medical Director for the US Family Health Plan. The position is charged with developing and managing a process of identifying quality issues and performance improvement activities through quantitative data collection, compilation and analysis of information. The position tracks and analyzes trends for management action and manages the preparation of reports necessary for plan management, and to meet the requirements of the DoD contract and Tricare regulations.

The QPI Manager assures that the US Family Health Plan meets the accreditation and other regulatory requirements of the contract with the Department of Defense. He/She assures that the department is in compliance with patient safety, program integrity, and other monitoring and oversight requirements as required by the Department of Defense. The QPI Manager also functions as the Health Plan Privacy officer, manages both the appeals and grievance functions, and has oversight responsibility for records management.

KEY RESPONSIBILITIES:

Quality Management:

  • Responsible for oversight and implementation of all quality management activities for the US Family Health Plan as chartered by the Quality Management Committee (QMC) or the Executive Director.
  • Identifies and initiates quality projects within the department and in collaboration with managers of functions that are delegated to external vendors.
  • Prepares the Annual Report and annual Quality Management Plan for Department of Defense.
  • Represents the department and the Health Plan both internally and externally for issues relating to quality and compliance.
  • Collects data, compiles information, analyzes and prepares reports necessary to meet the Department of Defense contract and other regulatory agencies.
  • Assures that all necessary reports are prepared in a timely manner to meet the needs of the USFHP Leadership Team and for reporting purposes to the DoD. Reports include: Complaint/Grievance trends, Quality Improvement Projects, Preventive Health Initiatives, Appeals quarterly reports, Occurrence reports, and TQMC patient safety reports.
  • Chairs the Quality Management Committee (QMC) and oversees quality improvement projects related to health promotion, disease prevention, chronic disease management, and patient safety.
  • Manages the annual HEDIS health outcomes data collection conducted by an external vendor. Analyzes results and identifies initiatives and programs for clinical quality improvement.
  • Responsible for the annual on site evaluation by the Department of Defense. Negotiates the agenda with the on-site team, prepares all requested documentation and prepares the Quality Programs and QI Initiatives presentations.
  • Works closely with USFHP management team and others to evaluate member and provider quality and to assist with program development.
  • Conducts medical record review audits, analyzes utilization data, HEDIS outcome measures and other relevant information to evaluate quality of care and safety. Uses clinical experience and knowledge to identify opportunities for improvement.
  • Interfaces with Manager of Care Coordination to support collaboration on joint ventures to improve utilization management of plan.

Patient Safety:

  • Manages and supports the Tricare Quality Monitoring Contractor medical record audit program.
  • Responds to individual breaches in patient safety and Serious Reportable Events (SRE’s). Assures that SRE’s and less serious patient care events are investigated fully, including root cause analysis, and are reported as required to the DoD.
  • Reviews occurrences/events on a monthly basis for trends related to individual provider, facility or type of event.
  • Reports individual occurrences and trends to the USFHP Clinical Quality Assurance Committee (CQAC), a peer review protected committee, for action by the Committee members. Documents the CQAC Committee proceedings with attention to the confidentiality afforded by the peer review protected status.

Regulatory Compliance:

  • Responsible for oversight of the USFHP Compliance Program.
  • Accountable for the ongoing evaluation and documentation of the level of USFHP compliance with Tricare regulations and contractual obligations.
  • Serves as a point person for all regulatory and compliance questions or issues conveyed by USFHP staff or external vendors.
  • Manages staff responsible for documenting USFHP compliance with Tricare regulations and contractual obligations. Staff maintains a compliance spreadsheet for the purpose of tracking, trending and reporting of current levels of regulatory compliance.
  • Serves as a liaison to the vendor performing medical record and claims reviews for the purpose of detecting potential fraud and abuse by USFHP contracted providers.
  • Provides periodic training to USFHP staff regarding HIPAA compliance and assures that all requirements are met, including required reporting if a privacy breach is detected.

Appeals and Grievances:

Responsible for overseeing a system to manage patient complaints and grievances which meets the terms of the DOD contract and Tricare standards.

  • Compiles appeal and grievance data, identifies and analyzes trends. Reports quarterly findings to the Quality Management Committee. Monitors corrective action plans.
  • Supports and participates in provider education initiatives regarding plan requirements.
  • Manages the provider and member appeal processes. Tracks and trends appeal data and initiates corrective actions, as necessary.
  • Chairs the USFHP Appeals Committee and acts as a liaison with the DoD and the Tricare Quality Monitoring Contractor (TQMC) for members seeking final level of appeal.
  • Maintains data on the status of appeals and grievances and reports quarterly to the QMC to assure compliance with timeliness and other requirements.
  • The Manager interviews and obtains information from providers, staff and patients in the course of ensuring the department is meeting established quality and safety standards.
  • Reviews medical record information on a need to know basis and extracts pertinent data relative to report preparation and complaint inquiry.
  • The manager corresponds in verbal and written form with patients, plan members and providers in resolution of quality of care complaints and other issues.

Other Responsibilities:

  • The Manager interviews, selects, hires, and terminates staff according to Human Resource policies for staff under area of responsibility.
  • Participates in the US Family Health Plan Alliance Clinical Quality Improvement Committee which shares best practices among the 6 national US Family Health Plans. Participates in monthly Alliance telephonic Committee meetings and may travel to Alliance or Tricare Quality meetings in Washington, DC or other locations.
  • Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.

‹‹‹1. Commits to recognize and respect cultural diversity for all customers (internal and external)

2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.

3. Performs other duties as assigned

REQUIRED KNOWLEDGE & SKILLS:

  • The Manager of Quality Management reports to the Vice President of Medical Management and Quality of US Family Health Plan. The position works collaboratively with the Senior VP and Executive Director in areas of regulatory oversight and performance improvement planning.
  • Analytic skills and the ability to interpret health care data.
  • Project management skills, including excellent organizational skills and the ability to manage multiple projects simultaneously.
  • Excellent verbal and written communication skills.
  • Teamwork skills and the ability to work collaboratively with both internal and external stakeholders.
  • Communicates effectively with internal and external customers with respect for differences in culture, values, and beliefs.
  • Ability to manage staff who do not have a direct reporting relationship to the position, including health plan staff as well as and external business partners.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

Education: Bachelor's degree in Nursing or Public Health required, master’s degree preferred.

Experience (Type & Length): At least two years experience in a managed health plan environment. Thorough clinical knowledge of population health and managed care.

Certification/Licensure: RN with current MA license required

Software/Hardware: Computer skills in Microsoft Office and database management

Other: Strong interpersonal, organizational and oral communication skills.

Ability to handle multiple projects, flexibility and problem solving skills.

[HOSPITAL or ORGANIZATION] is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment – with confidence and without fear.

Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence and convenience:

1. Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible.

2. Any COVID-19 related care takes place in designated areas away from other patients and their families.

3. Emergency Departments are reorganized to be a safe place to treat all emergency patients.

4. A stringent cleaning policy has been implemented throughout the hospital.

5. A strictly controlled visitor and masking policy is required for patient safety.

You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.

Application Instructions

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