Description

American Specialty Health Incorporated is seeking a Manager, CQA - Clinical to join our Clinical Quality Administration (CQA) department. This position will assist Clinical Quality Administration (CQA) and Health Services (HLS) leadership (e.g., VP, Director, Associate Director) in the management of Clinical Quality Administration and Health Quality Improvement functions and activities within the organization with focus on supporting various CQA committee meetings (e.g. PRC, QIC), practitioner hearings, clinical quality metrics, clinical QIA studies, clinical quality oversight, member grievances and clinical quality investigations.

Salary Range

American Specialty Health complies with state and federal wage and hour laws and compensation depends upon candidate’s qualifications, education, skill set, years of experience, and internal equity. $69,200.00  to $85,000.00 Full Time Annual Salary Range.

Remote Worker Considerations

Candidates who are selected for this position will be trained remotely and must be able to work from home in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and 10 Mbps upload speed).  

Responsibilities

• Assists in management and is accountable for all activities within assigned scope of authority. Ensures accuracy and productivity in project completion and works cooperatively with all internal and external contacts. Achieves and exceeds company standards in management of QA tasks. Manager will support and manage the following activities:
• CQA and HLS leadership in CQA/HLS daily functions
• Practice Review Committee including preparation of clinical documents, follow-up reports and member/practitioner communications.
• Quality Improvement Committee and Practice Review Committee including preparation of clinical documents, follow-up reports and member/practitioner communications.
• CQA administrative staff as needed, ensuring documentation sent to clinical consultants is complete and committee discussions and determinations are accurately reflected in committee minutes.
• Clinical Services Investigation Team (CSIT) activities with research, documentation and communications as applicable.
• Review of practitioner/provider medical records developing, writing, editing and updating inquiry letters, education letters, Corrective Action Plans (CAP), and termination letter language as needed.
• CQA practitioner CAP and CAP follow-up process supporting Team Leads, to meet expectations for accuracy and timeliness of CAPs and the CAP follow-up process and administrative support personnel related to the CAP and CAP follow-up process.
• Projects in support of department goals.
• Clinical Quality Evaluation (CQE) and CQA clinicians analyzing data and implementing practitioner corrective actions, as appropriate.
• Timeliness and accuracy of terminations, including necessary tracking, inbound and outbound communications, and reporting mechanisms.
• Development of annual HQI evaluation, HQI program and HQI Workplan.
• Clinical QIA studies in collaboration with HLS leadership.
• Clinical staff research of member grievances, review medical records, and produce reports to PRC and health plans as needed.
• Timeliness and accuracy of Practitioner Hearing process and required state/NPDB reporting.
• Accuracy and timeliness of reporting immediate terminations to appropriate health plans.
• Development, implementation, and maintenance of appropriate data bases (medical records, CAP, termination) to ensure data integrity and reporting needs in support of CQA/HLS department goals and deliverables.
• Accuracy and confidentiality of quality-related communications.
• Resolution of quality-of-care issues.
• Attend meetings with customers when requested by department leadership.
• Urgent/Emergent situations with emerging VPTR product.
• Oversight of evolving VPTR product and CQA activities.
• Health coaches and clinical staff as directed.
• Document subordinates’ performance; provide feedback, coach, counsel, and discipline.
• Participate in the hiring and termination process.
• Prepare and deliver quarterly assessments and annual performance evaluations of direct reports within required timelines.
• Increase department efficiency through introduction of system-based technology (e.g. automation of routine transactional functions).
• Serve as resource to directors, managers, and staff relating to compliance and/or procedural inquiries.
• Interact with ARF code development and ARF code annual review process.
• Support of CQA projects; including clinical quality investigations, CAPs, CAP follow-ups, grievance and appeal investigations, PRC, QIC, and the Clinical Performance System, ensuring process accuracy and timeliness.

Qualifications

• A licensed health care practitioner from an accredited health care college or university in one of the licensed health care specialties managed by ASH (DC, PT, OT, ST, LAc, ND, DPM), a physician (MD or DO), or Registered Nurse (RN) and a current, unrestricted license to practice the applicable health care specialty in the State of California.
• Advanced training, certification, or on-the-job experience in health care or Quality Administration.
• Minimum 3 years of clinical experience. Specific experience to include medical necessity review (preferred).
• Minimum 2 years health care administration. Specific experience to Health Quality Improvement (HQI) program implementation, including specialty health care operations, regulatory compliance, coordination of policy development, support of practitioner-based committees and experience in Quality Improvement (QI) data analysis preferred.
• Use of computer in health care application required.
• Knowledge of ASH Systems and Programs including the Clinical Performance System highly preferred.
• 1-2 years supervisory experience preferred.
• Credentials meet ASHG credentialing criteria.
• Demonstrated process development, research and writing abilities.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
• Ability to effectively organize, prioritize, multi-task and manage time.
• Demonstrated accuracy and productivity in a changing environment with constant interruptions.
• Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
• Ability to exercise strict confidentiality in all matters.

Mobility

Primarily sedentary, able to sit for long periods of time. 

Physical Requirements

Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in verbal and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs. Ability to travel within and outside State of California by car and/or airplane as required.

Environmental Conditions

Work-from-home (WFH) environment.

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex including sexual orientation and gender identity, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law. 

Please view Equal Employment Opportunity Posters provided by OFCCP here.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information.
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