RN Quality Assurance Manager, Clinical Systems

RN Quality Assurance Manager, Clinical Systems

This position is responsible for providing leadership oversight in the correct and effective use of decision tools used for utilization management activities including staff training. The position is responsible for managing multiple teams and resources. They work collaboratively with Clinical Operations and other Care Oregon Teams to ensure integration and support of organizational activities and goals across all lines of business.

The position is responsible for department planning, as well as developing, implementing and managing internal operations and vendor transactional quality assurance processes, reports, dashboards and workflows to ensure Care Oregon’s quality standards are achieved, and compliance requirements are met. Additionally, the role is responsible for communicating results, process improvements and remediation outcomes both laterally and horizontally.

Estimated Hiring Range: $ - $ Bonus Target:
Bonus - SIP Target, 5% Annual Current Care Oregon Employees:

• Develop and oversee implementation of (department) policies and procedures.
• Develops and oversees training documents, audit materials and educational resources.
• Conduct process trainings.
• Assist the Director in long- and short-term quality planning.
• Assure clinical systems align with regulatory and contractual requirements (Medicare and Medicaid) and organizational needs.
• Design, develop, and update clinical content through the review and understanding of information gathered from regulatory and organizational requirements.
• Develop Quality Assurance testing of clinical content and create and maintain documentation.
• Create and maintain tools and processes to verify accuracy and effectiveness of clinical systems.
• Analyze data and information to identify improvement opportunities and recommend changes/enhancements to processes.
• Develops and implements strategies to ensure compliance with internal and external plans of correction.
• Maintains records that demonstrate compliance with regulatory requirements and/or plans of correction.
• Keep abreast of regulatory expectations (state, federal and health plan) and inform staff and other stakeholders of these requirements.
• Keep abreast of standards for health plan quality operations related to responsible areas and develop plans to operationalize.
• Utilizes Quality Improvement methodologies as part of continuous improvement including root cause analysis, Plan/Do/Study/Act.
• Utilizes change management methodologies to communicate required changes to staff and other teams.
• Prepare internal business reviews and presentations as needed.
• Maintain up-to-date knowledge of clinical practices and Medicare and Medicaid guidelines.
• Serve as a clinical resource for both internal and external customers, including training of new content both created and as part of the product.
• Collaborate with Medical Directors and Clinical Operations leadership team for organizational criteria Develop project plans, monitoring tasks and ensuring on-time delivery of clinical content.

• Works collaboratively with other Care Oregon leaders and departments.
• Participates in internal and external work groups/meetings as required.
• Assures stakeholders are engaged in performance improvement processes.
• Develops a matrixed relationship with other Quality Assurance Leaders as necessary to assure efficient departmental functioning.
• Provides cross coverage for other departmental leaders.
• Assists in internal and external audits are requested.

• Manages team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
• Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
• Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
• Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
• Train, supervise, motivate, and coach employees; provide support toward employee development.
• Incorporate guidance from Care Oregon equity tools into people leadership, planning, operations, evaluation, and decision making.
• Utilize Care Oregon’s competencies to evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability…