[Hiring] RN Quality Assurance Manager @CareOregon

Role Description

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 CareOregon 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 CareOregon’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.

Qualifications

• Current unrestricted Registered Nurse (RN) license for State of Oregon
• Minimum 5 years’ experience in health plan quality operations, such as member rights, quality assurance, and/or utilization management
• Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program (preferred)
• Proficiency with nationally accepted clinical guidelines, such as InterQual or MCG (preferred)
• Experience developing quality and testing programs, processes and procedures from the ground up (preferred)
• Experience with applications and front and back-end system testing & technologies in multiple operating systems and environments (preferred)
• Experience in clinical content creation or medical writing (preferred)
• Experience with training and onboarding (preferred)
• Experience directing vendor testing (preferred)

Requirements

• 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.

Benefits

• Competitive pay
• Bonus opportunity
• Comprehensive benefits package including medical, dental, vision, life, AD&D, and disability insurance
• Health savings account, flexible spending account(s), lifestyle spending account
• Employee assistance program and wellness program
• Discounts and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
• Strong retirement plan with employer contributions
• PTO and Paid State Sick Time based on hours worked/scheduled hours
• Paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility

Company Description

CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.