UM Quality Manager-Medicaid

• Under general supervision of the Program Director and in collaboration with the administrative team and Medical Director, the Quality Manager oversees the department responsible for internal and external Quality Review processes in accordance with the goals of the Colorado HCPF Utilization Management Contract.

• The Quality Manager also assists with the development of requirements for system configuration and reports.

• Ensure that the program meets or exceeds all contract Performance Standards.

• In collaboration with the Program Director, UM Manager, and clinical supervisors, responsible for the quality monitoring activities, including identifying areas of improvement and plan implementation of improvement areas.

• Oversee contract-specific Quality Program, providing guidance to the management team and client regarding quality-related issues.

• Focus on risk management, operations and infrastructure, performance monitoring and improvement, and consumer protection and empowerment in the day-to-day management of quality assurance activities for the contract.

• Manage program staff IRR and clinical documentation audit processes.

• Work collaboratively with clients and stakeholders to develop process improvements.

• Verify adverse decision notifications were handled and documented per the policies of the state of Colorado.

• Consult with other program managers and supervisors regarding member and/or provider complaints and grievances as needed.

Requirements

• Bachelor’s degree in Nursing.

• An active, unrestricted Registered Nurse (RN) license in any U.S. state.

• Clinical experience.

• 3+ years of experience in quality management and project management.

• 2+ years of experience recommending, developing, and reviewing quality assurance standards, policies, and procedures in accordance with company standards.

• Experience working in a Fee-for-Service (FFS) or Managed Care Medicaid quality role.

• 2+ years of experience in data collection, process improvement, ensuring quality measures/metrics, and template creation for public notices, training, and surveys.

• 3+ years of experience in Utilization Management (UM) / Utilization Review (UR).

• 3+ years of experience working with external clients and customers.

• Set high standards of performance for self and others and assume responsibility and accountability for successfully completing assignments or tasks.

• Knowledge of National Committee for Quality Assurance (NCQA) / Utilization Review Accreditation Commission (URAC) standards.

• Ability to maintain a positive attitude and contribute both as an individual and a team member to achieving the department's goals.

• Ability to professionally respond to change and handle multiple and changing priorities with sometimes conflicting deadlines.

• Knowledge and willingness to become a subject matter expert and thought leader for the designated program(s).

• Demonstrated proficiency in MS Office applications.

• Excellent verbal and written communication skills.

• Highly organized.

• Excellent customer service skills.

• Master’s in Nursing or another health-related field.

• Certified Professional in Healthcare Quality (CPHQ).

• 5+ years of experience in quality management and project management.

• 3+ years of experience working with a Medicaid population.

• Experience with State Medicaid programs.

• Knowledge of Colorado Medicaid.

• Experience in services such as DME, Medical/Surgical, Psych/BH, Pediatric Home Health/PDN, Physician Administered Drugs, and other outpatient services.

Benefits