Manager Quality Improvement (PQI)

Manager Quality Improvement (PQI)

CalOptima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Manager Quality Improvement (PQI) and help shape the future of healthcare where you'll be an integral part of our Quality Improvement team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.

If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

***Training will be held in the office for the first 3 weeks from 8:00am - 5:00pm, on Tuesdays and Thursdays.

The Manager of Quality Improvement for Potential Quality Issues (PQIs) will be responsible for overseeing peer review functions to ensure compliance with regulatory, accreditation and contractual requirements related to quality of care. You will also manage the endtoend PQI process to ensure timely identification, evaluation, investigation and resolution of potential quality concerns related to member care and reduce member safety risks. You will lead a team of clinical and nonclinical staff who conduct PQI reviews, collaborate crossfunctionally with internal departments and provider partners and drive improvements that support patient safety, clinical quality and compliance. Additionally, the incumbent will work collaboratively with the Quality Improvement leadership and with internal business units to develop, maintain and evaluate the Quality Improvement Health Equity Transformation Program (QIHETP) and Work Plan. You will work to enhance and strengthen CalOptima Health's quality improvement and health equity infrastructure, including program, policy, contract compliance and statutory and regulatory obligations with National Committee for Quality Assurance (NCQA), the Department of Health Care Services (DHCS), the Department of Managed Health care (DMHC) and the Centers for Medicare & Medicaid Services (CMS). Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

50% - Leadership Functions

Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.

Manages employees directly and is responsible for selecting, training, developing, reviewing, and setting department and individual performance goals.

Ensures consistent workflows, documentation quality and adherence to regulatory expectations.

Promotes a culture of accountability, excellence and continuous improvement with provider partners through exemplary leadership practices.

Leads the review of complex and sensitive cases, including those involving potential adverse events, quality of care concerns and patient safety incidents and escalates to the Credentialing Peer Review Committee (CPRC), the Quality Improvement Health Equity Committee (QIHEC), subcommittees or other internal review bodies, as appropriate, for action.

Participates in and presents at CalOptima Health committees, such as Delegation Oversight and the Utilization Management Committee (UMC).

Facilitates and supports the CPRC, working closely with the Committee Chair, medical directors, legal counsel, members and providers to ensure cases are reviewed fairly and that the Committee's recommended actions are implemented.

Participates in internal and external audits, regulatory reviews and corrective action activities related to PQIs.

45% - Program Oversight

Leads the day-to-day PQI operations, including timely intake, triage, investigation, case review, documentation and case closure in accordance with CalOptima Health policies and regulatory standards.

Engages, collaborates and educates cross-functional departments, including Medical Management, Provider Relations, Office of Compliance, Utilization Management, Grievances & Appeals and other departments, to gather case information necessary for accurate and fair case evaluations and drive quality improvement as part of the PQI process.

Identifies trends, risks and systemic issues emerging from PQI findings and develops recommendations and action plans to improve provider performance and member safety.

Drives the development, maintenance and annual updates of PQI policies, procedures, workflows and related clinical quality sections of CalOptima Health documents, such as the provider manual or member handbook, in alignment with regulatory changes and operational needs.

Ensures confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA), peer review, post-hospital discharge medication, critical incidents and provider preventable conditions (PPC) and all applicable regulations and submits reports to appropriate regulatory entities.

Partners with Information Technology (IT) to operate, enhance and troubleshoot the care management system used for PQI processing and develops and refines reporting capabilities and systemgenerated metrics.

Collaborates and contributes PQI data, analysis and activities to the QIHETP Description, Work Plan and annual Evaluation.

Oversees the development, maintenance and evaluation of the QIHETP and Work Plan in collaboration with leadership and ensures documents comply with accreditation, contractual and regulatory requirements.

5% - Other

Completes other projects and duties as assigned.

Do You Have What the Role Requires?

Bachelor's degree in nursing PLUS 5 years of experience in clinical operations, quality or grievances within a managed care setting required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

3 years of leadership experience, including direct supervision of staff required.

2 years of experience related to quality of care investigations required.

You'll Stand Out More If You Possess the Following:

Master's degree in nursing, health care or related field.

Certification in quality or process improvement (e.g., Certified Professional in Healthcare Quality, Lean Six Sigma Green Belt).

2 years of experience in quality management or improvement within a managed care setting.

2 years of experience in an acute care hospital.

What the Regulatory Agencies Need You to Possess?

An unrestricted Registered Nurse (RN) license to practice in the state of California.

Your Knowledge & Abilities to Bring to this Role:

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

Work independently and exercise sound judgment.

Communicate clearly and concisely, both orally and in writing.

Work a flexible schedule; available to participate in evening and weekend events.

Organize, be analytical, problem-solve and possess project management skills.

Work in a fast-paced environment and in an efficient manner.

Manage multiple projects and identify opportunities for internal and external collaboration.

Motivate and lead multi-program teams and external committees/coalitions.

Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms and other printed materials and information.

Ability to speak (enunciate) clearly in conversation and general communication.

Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.

Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.

Lifting and moving objects, patients and/or equipment less than 10 pounds

Ways We Are Here For You

You'll enjoy competitive compensation for this role.

Our current hiring range is: Pay Grade: 314 - $99,902 - $159,843 ($48.03 - $76.8476).

The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.

This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**)

***Training will be held in the office for the first 3 weeks from 8:00am - 5:00pm, on Tuesdays and Thursdays.

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