Summary: Under the direction of the Chief Executive Officer (or as may be otherwise designated), this position is responsible for corporate quality assurance and accreditation activities and corporate utilization review/case management services and procedures.
Quality Assurance & Compliance
1. Oversee corporate quality assurance activities and communicate with Quality Assurance Committee of the Board of Directors through the CEO. Maintain the corporate quality assurance plan. Promote quality improvements and ensure adherence to quality standards and attention to detail through all levels of organization. Advise CEO of opportunities to improve delivery of services and resolve identified problems.
2. As specifically directed by the CEO, and in cooperation with all divisions, develop and implement corporate-wide quality indicators to monitor each division’s effectiveness. Develop cross-training protocols for applicable positions to ensure member/client access to services is not compromised.
3. Ensure compliance with national accreditation process, corporate policies and procedures, and applicable state/federal statutes and regulations. Oversee corporate accreditation process, as directed. Ensure all state license/certification requirements are met. Oversee maintenance of current state name registrations and trademark registrations.
4. Oversee (perform) divisional quality audits to ensure compliance with clinical policies and procedures, ERISA/HIPAA/MHPAEA/PPACA/URAC, and applicable state requirements. Report to CEO and division managers. Stay current and informed on all applicable federal and state regulations and compliance requirements. Serve as a resource for all divisions and external clients and providers as appropriate.
5. Assist in orientation and training of clinical professional staff, and provide ongoing guidance and administrative direction to division staff regarding clinical policies and procedures, and documentation standards. Provide input into annual performance reviews.
6. Oversee review and follow-up of patient satisfaction survey concerns and issues. Serve as primary liaison for the QA department for the identification and resolution for patient complaints and issues. Ensure adequate QA monitoring of providers in compliance with policies and applicable regulations. Ensure documentation of member/provider complaints to resolution. Utilize QA department data to improve case management effectiveness and corporate customer service/patient satisfaction. Assist in the maintenance/improvement of 96% patient satisfaction rate and 90% provider satisfaction rate.
7. In coordination with other divisions, perform utilization/cost monitoring and tracking functions on appropriate client contracts, including impact of MHPAEA and PPACA on client costs. Conduct requested chart audits on specific issues. Serve as a resource to Corporate Relations and Data Processing in the development and updating of client SBC’s, SPD’s and other documents to ensure accurate and timely input of benefits into the IT systems used to coordinate and use the client benefit information. Ensure all client benefit plans are parity and ACA compliant.
8. Maintain and ensure compliance with clinical and corporate policies, procedures and utilization review guidelines. Oversee all corporate utilization review/case management services and procedures, including patient complaint and appeals process. Recommend and implement changes or additions as appropriate. Perform administrative case reviews and audits, to include regular quarterly chart audits, supervisory referral audits and others as directed or appropriate. Ensure the divisions’ compliance with URAC, ERISA, HIPAA, MHPAEA, PPACA, and all other applicable regulations/standards.
9. In cooperation with IT Division, assist in the development and implementation of computerized clinical and provider systems, case management, tracking, and UR systems.
10. Assist all divisions as requested in support services related to specific or potential contracts. Review all general business, IT, client and provider affiliation agreement language and make recommendations regarding same. Assist in preparation of RFP or other proposals as requested.
11. Maintain corporate, departmental and quality assurance policies and procedures. Recommend new policies/procedures as deemed appropriate. Recommend revisions to forms as appropriate.
12. Assist in preparation of annual corporate goals and objectives. Oversee preparation of annual divisional corporate goals and objectives and divisional action plans in a timely manner; monitor objectives and due dates bi-monthly.
13. In cooperation with Executive Vice President & Managed Care Officer as may be specifically requested, assist other division heads in the general responsibility for the Corporation’s day-to-day operations in the CEO’s absence.
14. Serve as liaison with treatment providers, clients, patients, and others, as directed. Resolve problems on a timely basis. Serve as the corporate liaison regarding lawsuits or complaints filed against the company, under the direction of the CEO.
15. Participate in on-going marketing and provider relations efforts, as directed. Participate in special projects, on-going research and public relations efforts as appropriate. Maintain information on competition, provider rates by region or city, national statistics and relevant changes in the field. Make recommendations on product line enhancements. Prepare reports and conduct surveys as requested or deemed appropriate.
16. Maintain corporate and departmental budgets. Assist in preparation of annual budgets. In coordination with the VP, Administrative Services and the CEO, maintain general and professional liability insurance coverage policies.
17. Communicate and advise the CEO on developments in the field. Keep CEO abreast of activities and provide regular updates and reports. Monitor the developments, practices and forms/protocols of competitors.
18. Perform other related duties as directed or deemed appropriate. Maintain professional competency through continuing education, conferences, and internal training. Prepare written articles/materials and presentations on appropriate topics as appropriate for increased visibility in the community.
– Masters degree preferable.
– Five years quality assurance experience required, preferably in PPO/HMO or similar setting
– Experience in managed care/PPO environment.
– Some experience/involvement in mental health field preferred.
– Familiarity with case management/util. review functions.
– Familiarity with computerized applications (PCs, Word, Access, internet).
– Experience in services to business, industry preferable
– Experience with fiscal issues, rate negotiations, contractual terms, QA/compliance issues.
– Excellent communication skills (written and oral), organization skills, and problem-solving abilities.
– Experience in group presentations/speaking preferable.
– Experience in staff supervision/training.