Organizational Quality Improvement & Accreditation Manager

Apply on line at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture, which is positively reflected into the communities we serve.

Position Summary:

Under the supervision of the Senior Director, Quality Improvement / Utilization Management, the Manager, Organizational Quality Improvement and Accreditation (MOQIA) is responsible to manage the development, modification, implementation and coordination of systems and processes necessary to meet all National Committee for Quality Assurance (NCQA) accreditation and certification requirements. The MOQIA is also responsible for the management and coordination of efforts to ensure that quality improvement (QI) programs are developed using a data-driven focus that sets priorities for improvements aligned to ongoing strategic objectives and all regulatory compliance standards related to QI and NCQA. In addition, this position is responsible for management oversight of receipt, investigation and processing associated with member/provider complaints, grievances and appeals.

Primary Job Duties and Responsibilities:

NCQA Accreditation

• Execute an organization work plan/NCQA tracker to achieve accreditation; coordinating NCQA survey activities, and ensuring ongoing compliance with NCQA accreditation standards

• Identify gaps and risks; providing regular status reports from NCQA tracker to appropriate management and developing strategies to mitigate risks and gaps considering business needs and compliance requirements

• Serve as AlohaCare’s subject matter expert on NCQA health plan accreditation and standard interpretation; educating relevant managers and staff on standards and assist with operationalizing requirements

• Manage and oversee preparation for NCQA site visits and surveyor activities including, maintaining NCQA ISS tool, completing applications, preparatory audits, mock reviews and documentation

• Work within organizational wide, cross-functional and multi-disciplinary teams to bring each business area to a state of readiness, ensuring all NCQA compliance issues are addressed and Plans of Correction are completed timely and noted on NCQA tracker.

• Conduct ongoing NCQA readiness monitoring and auditing activities utilizing the NCQA tracker to identify risks and assist department managers with corrective actions to ensure continuing compliance with NCQA standards

Quality Improvement (Operational)

• Functions as a leader, facilitator or member of QI workgroups and project teams (QITs)
• Develop, prioritize, and manage the programmatic and policy components on the NCQA Policy tracker of Quality Improvement projects and/or initiatives as they relate to QI initiatives, compliance and accreditation

• Collaborates on the design of the information technology infrastructure required to support a health plan performance and quality improvement system. Ensures needed data is collected on a timely basis, regular reports on progress are distributed, and makes recommendations for future improvements based on the data

• Ensure that tracking and reporting is performed per QUEST Integration, CMS, NCQA, and other accreditation/regulatory requirements and AlohaCare policies and procedures

Grievances and Appeals
• Oversees the daily operations related to the grievance and appeals process at AlohaCare, with the specific goals of promoting consistency, efficiency and accuracy and to maintain NCQA accreditation, regulatory compliance, and to ensure adherence to all HIPAA guidelines

• Continually evaluates operations and identifying process improvement needs. Identify irregular trends with grievances and appeals and member complaints; work with other areas as appropriate to identify root causes and appropriate steps for resolution

• Monitors and works with member-facing departments to ensure that grievances and appeals and member complaints are resolved and reported to the Grievance & Appeals team

• Prepares all Complaint, Grievance & Appeals reports, as required by QUEST Integration, CMS, or other regulatory agencies per format and timeframes specified. Report drafts are prepared in advance with sufficient time for internal management review

• Reviews and revises as necessary all AlohaCare policies and procedures related to member and provider complaints, grievance and appeals to assure that these policies and procedures are compliant with current requirements from QUEST Integration, CMS, NCQA, AlohaCare, or other accreditation and regulatory agencies

• Works proactively to keep the executive leadership apprised of team performance, projects and issues

• Performs other duties as required

• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Supervisory Duties:

• Performs general management duties to include: the hiring process, training, work assignments, performance evaluations, development of career goals, and disciplinary action
• Provides timely guidance and feedback to help staff strengthen specific knowledge and develop skill areas to accomplish tasks or solve problems

Required Competencies & Qualifications:

• Bachelor’s Degree or equivalent combination of demonstrated experience and education
• 3-5 years of relevant health sector experience
• 3-5 years of leadership and/or management experience
• Prior health care accreditation and/or extensive quality improvement experience
• Working knowledge of Medicaid and/or Medicare
• Demonstrated success with Business Process Improvement and Workforce Effectiveness projects
• Project Management experience or skills
• Demonstrated ability to effectively prioritize and execute tasks and special projects
• Demonstrated experience in data collection, presentation and action plans
• Strong Verbal and Written Communication skills
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
• Maintains stable performance under pressure or opposition (such as approaching deadlines or job ambiguity); handles stress in a manner that is acceptable to others and to the organization

Preferred Competencies & Qualifications:

• Health Plan experience
• Knowledge of NCQA accreditation processes and standards
• Working knowledge of Hawaii QUEST Integration Program
• Experience in conducting and/or directing comprehensive and extensive grievance/appeals investigations

Physical Demands/Working Conditions:
• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.

Position Description »