Manager, Clinical Quality Improvement - Medical Mutual : Job Details

This is a remote opportunity in Ohio. Note: quarterly and occasional/ad hoc/situational in-office requirement in Brooklyn, Ohio.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Responsibilities

• Manages Clinical Quality Improvement program and staff to include the activities of HEDIS, Medicare Stars, and Provider Quality.
• Devises and manages the implementation of strategies to improve clinical outcomes and promote wellness for all lines of business.
• Ensures coordination of clinical quality improvement (CQI) activities among functional areas, monitors the progress of CQI activities against the annual CQI work plan and ensures potential quality of care issues are channeled appropriately for investigation and resolution.
• Manages the design, development, and implementation of clinical quality improvement projects, clinical practice guidelines and health promotion projects. Directs the clinical abstraction process to coordinate chart review for HEDIS and report back findings to network providers.
• Provides advice and consultation to management and department staff. Maintains expertise of national accreditation standards, clinical quality regulations and changes within the clinical field and assures compliance across assigned managed care product lines. Participates and chairs various committees.
• Coordinates client based medical informatics analysis. Oversees the collection, analysis and reporting of data relative to health-related baselines, outcomes and return on investment.
• Performs other duties as assigned.

Qualifications - External

Qualifications

• Bachelors degree in Nursing, Healthcare Administration or related healthcare field required; Masters degree preferred.
• 8 years progressive health care experience in case, utilization, or quality management; 3 years of which are in management or high-level individual contributor role.
• Certified Professional in Healthcare Quality (CPHQ) preferred.
• Registered Nurse with current State of Ohio unrestricted license preferred.
• Comprehensive knowledge of CMS Part C regulations, HEDIS, Medicare Stars rating and NCQA standards.
• Comprehensive knowledge of process and performance improvement methods and tools: Plan Do Study Act (PDSA) Define, Measure, Analyze, Improve and Control (DMAIC).
• Knowledge of financial/business analysis techniques.
• Knowledge of clinical care models and quality frameworks.
• Demonstrated ability to design, plan and deliver programs to large and small groups.
• Strong verbal and written communication skills.
• Intermediate to advanced Microsoft Office skills.
• Strong project management skills with the ability to handle multiple, concurrent projects through to completion.