Director, Quality Management
New Century Health is leading transformative change in specialty care management. By combining medical management expertise with a deep understanding of healthcare informatics, physician management and healthcare technology systems development, we generate insights that drive leading edge and effective innovation. What does this mean to you? It means that when you join us, you will be a key contributor to one the fastest growing healthcare services in the National Oncology and Cardiology care management space today. With your knowledge, skills and abilities, you will impact the delivery of care and directly contribute to our ability to positively impact and meet the critical unmet needs of patients suffering from all types of cancer.
We support our employees with an outstanding benefit package that features programs like employee paid medical benefits, 100% match on your 401k contribution up to 4% of your base salary, generous tuition reimbursement, as well as above average paid time off. If you are interested in working with some of the most dedicated, passionate and smartest people on the planet, express your interest in speaking with us and we will respond immediately.
SCOPE & RESPONSIBILITIES OF ROLE:
This role is responsible for the overall Quality Management leadership for the Utilization Management and Claims Operations department at New Century Health. Responsible for regular monitoring, proactive assessment, and timely risk mitigation of day-to-day quality performance in complying with contractual commitments. Ownership for establishing strategic plans, policies and procedures at all levels so operational quality will meet or exceed customers’ needs and expectations in delivering overall program objectives.
The Director, Quality Management is accountable for leading payer audits and timely closure of open items to maintain high client satisfaction. Also responsible for leading education and training initiatives of UM and Claims staff to ensure continuous improvements. This role owns the maintenance of quality metrics and monthly internal and external communications.
KNOWLEDGE, SKILLS & ABILITIES:
- Knowledge of operational, financial, quality assurance, and accreditation standards for Commercial, Medicare, and Medicaid Payers
- Strong Utilization Management process knowledge supported by proven ability to lead external audits
- In-depth knowledge of URAC and/or NCQA accreditation requirements
- Subject Matter Expert on contract interpretation for QI and ability to lead/develop QI initiatives and CQI for proactive quality management
- Strong claims quality/ audits knowledge with experience in leading external audits (Medicaid, Commercial, Medicare)
- Expertise in the end-to-end management of corrective action plans (reactive and proactive)
- Ability to manage and effectively prioritize fluctuating workload utilizing time management techniques
- Ability to summarize technical issues and communicate effectively to non-technical audiences
EXPERIENCE, EDUCATION, LICENSES & CERTIFICATIONS:
- BS in Healthcare Administration or related field (required)
- 10 years of equivalent work experience in auditing with emphasis on health utilization and/or quality improvement (required)
- Oncology Nurse Certification in a state or territory of the United States (preferred)
- Six Sigma Certification or Certified Professional in Healthcare Quality (preferred)
- Advanced analytical and technical skills in Excel and BI tools (preferred)
ESSENTIAL JOB FUNCTIONS:
- Specific vision abilities, including close vision, operate computer screen for extended periods of time
- May be required to sit or stand for extended periods of time
- Ability to read, write and speak the English language fluently
- Ability to travel up to 10%