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Director of Quality Improvements and Accreditation (NCQA)

Miramar, FL

Unique opportunity to provide quality oversight of utilization management “UM” functions in compliance with a rapidly growing integrated healthcare organization in Southern Florida.  

Can be 100% REMOTE.

Will consider a FL Compact RN license 

The ideal candidate will ensure that the UM procedures and delegation expectations are synchronized and administered with appropriate and timely quality of care and services.

Responsibilities

  • Facilitate continuous improvement in UM/QM and clinical operations through collaboration with other departments and contracted health plans and continuous monitoring of clinical metrics through QA activities
  • Ensures departmental and intra-departmental compliance standards with regulatory and accreditation agency are being met
  • Manage development of policies and procedures related to QA activities, reviews, and delegation oversight requirements
  • Manage regulatory audits, including preparation and monitoring of any corrective plans, timely collections of reporting with data analysis to meet quality and delegation requirements
  • Fulfill and maintain compliance with federal, state, and NCQA requirements including corrective action plan (CAP), monitoring CAP activities, and providing education and tools as needed
  • Collaborate with health plans, downstream provider groups, and accreditation authorities as necessary
  • Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, and completing all requirements for ongoing licensures and certifications
  • Facilitate QA-related collaborative interaction with health plans, downstream provider groups, and accreditation authorities
  • Monitor compliance with provider organization quality background investigation and subsequent report to Credentialing Committee

Skills

  • Superlative organizational, writing, and communication standards
  • Self-motivated with the ability to work autonomously
  • Working knowledge of Outlook, Excel, Word, and Adobe Acrobat Pro
  • Detail-oriented with the ability to work on multiple, competing, priorities and is extremely organized
  • Possess analytical, verbal, and written communication skills, able to interface with UM and interrelated process owners and maintain effective working relationships with others

Requirements

  • Bachelor’s degree with a focus in healthcare administration; Master’s degree (MHA) preferred
  • Minimum of three years of experience in a health plan/ hospital setting primarily in UM/compliance function
  • Some home healthcare experience preferred
  • Experience with Utilization Management or Quality Improvement Plans (QIP) with InterQual and/or Milliman, CMS, and peer reviewed guidelines required
  • Valid Registered Nurse (RN) REQUIRED


 
 
 
Contact information:
________________________________________________
 
Recruiter
Max Populi, LLC
4628 Bayard Street, #207
Pittsburgh, PA 15213-2750
Tel: (412) 567-5279
Fax: (412) 567-5198
e-mail: jobs@maxpopuli.com
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