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Kaiser Permanente Careers

Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Clinical Quality Oversight Director

Location: Atlanta, GA Additional Locations:
Job Number: 868771 Date posted: 03/10/2020
Description:
The Clinical Quality Oversight Director promotes the delivery of reliable, effective, consistent and safe care and service for all members in all venues in partnership with key leaders. This position provides direct oversight, accountability and responsibility for the Clinical Quality Management programs which consist of Complete Care, Population Health, HEDIS Effectiveness, Health Education, Nutrition and Sure Net programs. Responsibilities include developing a region-wide strategic plan for complete care model, population health and care management functions including population health management, care management, disease specific care management, quality improvement, health education and care gap closures. He/she is responsible for developing, managing, initiating and implementing processes, programs and initiatives related to these areas to improve patient outcomes, reduce patient risk and assure cost effectiveness, high quality care and services. This position develops and coordinates an ongoing communication for clinical quality oversight and regulatory support for NCQA, CMS and other governing bodies. This position reports to the VP of Quality and works in collaboration with The Southeastern Permanente Medical Group (TSPMG) physicians, Southern California -(SCAL) Complete Care Quality Team, KFHP leaders, Hospitals and contracted facility leaders.

Essential Responsibilities:
  • Population Health: Leads the development and execution of a comprehensive population health management strategy - including protocols and processes for population health, outreach, care management, case management and care gap closure strategies and effectiveness metrics.
  • Develop and implement systems to engage patients in their health care through care coordination, care management, and outreach.
  • Identifies population health best practices from internal and external sources and disseminates them among clinical leadership and the team.
  • Acts as a liaison within Kaiser Permanente and the community and other population and care management partners, including medical groups and health plans.
  • Oversee and aligns our quality improvement program and metrics with evidence-based standards, population health goals and external performance requirements.
  • Develops, analyzes and creates presentations from performance data reports for internal and external customers, including population/panel health reports for outreach, health plan performance guarantees, etc.
  • Provides consultation on the development and implementation of protocols for Registered Nurses, Licensed Practical Nurses, Pharmacists, and others involved in Population Care Management, Panel Management, regional outreach, and other related programs, as required.
  • Participates in appropriate committees and workgroups and represents regional perspectives at interregional collaborative meetings. Participates in or assign a delegate to Quality Performance Improvement workgroups as needed.  Co Chairs the Quality Oversight Committee-(QOC) and Service Quality Resource Management committee-(SQRMC). As a senior contributor to the Quality team, may support quality program, process improvement initiatives, strategies, outcome measures and reporting.
  • Works in collaboration with SCAL Quality resources to coordinate proactive encounter enhancements, HEDIS effectiveness measures, outreach programs and quality programs (specifications, recharge agreements etc).
  • Health Education: Provides oversight for the Health Education activities to include education classes, consultation, biometric screening, off site, office visits, health prevention programs, ensuring surveillance, treatment optimization and complex care coordination.
  • Leads development and execution of health education programs to include protocols and processes, workflows, developmental level procedures, communication plans, care gap closure strategies, effectiveness metrics as well as implementation of new regulatory and accreditation standards.
  • POE/HEDIS: Consulting for review and implementation of proactive office care tools for the Kaiser Permanente Georgia region to include collaborating with all stakeholders, senior leaders, providers, and front- line staff to ensure successful launch of all tools to meet goals, improve member health, quality metrics, service experience and affordability. Develop and implement communication and change management plans to drive workflow communication for new processes on execution for strategic initiatives. Designs and delivers presentations to executive sponsors and other key stakeholders to report on resource needs, results and issues that are of immediate risk.
  • In collaboration with KPGA Clinical Operations and Southern California partners, ensure the Complete Care model is fully integrated and supported across the  program, maintain Proactive Office tools and enhancements  functions: Care Gap closures, outreach calls, HEDIS effectiveness, quality program engagement, POE specification, outreach programs and aligned strategies to ensure positive patient outcomes, High Priority measure and maintain CMS Five STAR.
  • Serves as consultant to regional senior leaders and chiefs on effective population care management approaches.
  • Operational Excellence: In partnership with KFHP and TSPMG supports Operational Excellence strategies, engaging the front- line staff, working to reduce waste and supporting the sharing of best practices.
  • Communicates information and results across the region and medical office buildings as appropriate.
  • Collaborates with partners with senior leaders to evaluate and prioritize population needs (i.e. performance guarantees, high risk populations, etc).
  • Responsible for meeting NCQA standards and CMS regulatory requirements including Special Needs Program (SNP) and Chronic Care Improvement program (CCIP). Develops and executes on all NCQA quality improvement plans (QIP).
  • Identifies opportunities to improve care provided through elimination of redundancy, establishment of transitional programs and opportunities for improved quality and program effectiveness.
  • Other Duties: Facilitates project and sponsor meetings to drive effective strategic planning, decision making, problem solving and conflict management, balances schedules, scopes and budget renegotiating with business owners and sponsors as necessary; escalates project issues, risk and challenges timely.
  • Manages program implementation and day to day operations, including performance metrics, logistics, budgets, staff selection, training, competency, and staff supervision.
  • Establishes and maintains collaborative, results oriented working relationships with executive sponsors, business owners, peers and other key stakeholders. Serves as thought partner and business advisor to leaders at all levels.
  • Demonstrate strong business acumen and healthcare industry expertise; understands organizational environment and impact on project success. Consults with executive sponsors, business owners and other stake holders to develop and manage project structure, charter timeline, roles & responsibilities, metrics, scorecards, budgets, ROI analysis, business cases and working agreements throughout the life of the project.
  • Basic Qualifications:
    Experience
  • Minimum ten (10) years of experience in health care is required.
  • Minimum eight (8) years of progressive experience in management with understanding of health care reporting and health care analysis.
  • Minimum seven (7) years in direct management.
  • Education
  • Bachelor's degree in business administration, health care administration, operations research, public health administration, nursing OR four (4) years of experience in a directly related field. 
  • High School Diploma or General Education Development (GED) required.
  • License, Certification, Registration
  • N/A.

  • Additional Requirements:
  • Strong personnel management capabilities and leadership skills.
  • Proven ability to determine key business issues and develop effective action plans from multi-disciplinary perspectives.
  • Demonstrated ability to conduct and interpret quantitative and qualitative analysis.
  • Ability to use computer systems to manage chronic disease populations and the ability to teach these systems to others.
  • Computer skills, including proficiency with Microsoft Office Suite programs, with an emphasis on Word and Excel; ability to learn new systems; experience entering and working with data; and comfort and experience using mobile technologies.
  • Strong communication and follow through skills with a focus on collaboration and customer service.
  • Strongly prefer a candidate that will have a demonstrated understanding of and competence in serving culturally diverse populations.

  • Preferred Qualifications:
  • Experience in program development, collaboration, and contract management with external customers preferred.
  • Master's degree preferred.
  • CPHQ certification preferred
  • Primary Location: Georgia,Atlanta,Regional Office - 9 Piedmont 9 Piedmont Center 34 Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 4:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Director/Senior Director Job Category: QA / UR / Case Management Department: Population Management Travel: Yes, 10 % of the Time Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

    About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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