Manager, Provider Quality Oversight

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

At Inland Empire Health Plan (IEHP), we believe the highest quality of care should be delivered to all in the Inland Empire.  We are thinking beyond the way Quality is viewed today – we believe it should be holistic and transformative.  IEHP’s provider incentive programs serve an important role in achieving IEHP’s quality goals.
Reporting to the Director of Quality Management, the Manager of Provider Quality Oversight is responsible for:

• Leading the daily operations of the Potential Quality Incident/Provider Preventable Condition and clinical reporting nurse teams.
• The daily activities and functions of their responsible areas to include but not limited to the management, evaluation, mentoring, and coaching of Team Members.
• Ensure the complete review of Quality-of-Care cases, adherence to standard work, reporting accuracy, and compliance with IEHP policies, Local, State, and Federal laws, and regulations.
• The planning and implementation of any quality audit initiatives, programs, and processes identified by IEHP’s Quality System.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks 

1. Responsible for managing direct reports to ensure effective resource management and prioritization of work in support of meeting Quality and Organizational goals and priorities.
2. Responsible for the development, management, implementation, and evaluation of all areas of responsibility including, but not limited to, Potential Quality Incidents (PQI)/Provider Preventable Conditions (PPC) processes, Quality Reviews, and clinical audits of IEHP Providers to ensure clinically appropriate billing.
3. Provide oversight and management of the PQI and PPC processes and staff to comply with IEHP policies, Local, State, and Federal standards, and regulations.
4. Collaborate with appropriate internal and external departments, team members, and entities to achieve organizational quality initiatives, as assigned.
5. Responsible for the development, maintenance, implementation, and adherence to departmental policies and procedures, standard operating procedures, and job aides.
6. Participate in Quality Management activities and projects to ensure interventions meet project goals. Participation also includes compiling results and presenting a report to the Director of Quality Management, regulators and/or IEHP committees as appropriate.
7. Lead, prepare, and coordinate appropriate Provider Quality Review department related internal meetings. Represent IEHP in external meeting related to key areas of responsibility as appropriate.
8. Any other duties as required to ensure the Health Plan operations are successful.
9. Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance.
10. Establish and maintain effective working relationships with others throughout the organization.

Education & Requirements

• Five (5) or more years of any individual or combined healthcare experience in quality management, quality assurance, quality improvement, utilization management, case management, acute care, and/or ambulatory care setting
• Three (3) or more years of experience in a supervisory or leadership role in any healthcare setting
  • Experience in an HMO or Managed Care setting is preferred

• Bachelor’s degree in Nursing from an accredited institution required

  • Master’s degree in Nursing from an accredited institution preferred
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required 
  • Certified Professional in Healthcare Quality (CPHQ) certification preferred

Key Qualifications

• Knowledge of clinical audits, including medical record reviews
• Intermediate knowledge of word, excel, and PowerPoint. Intermediate computer skills
• Excellent verbal and written communication skills
• Builds effective work relationships

Start your journey towards a thriving future with IEHP and apply TODAY!

Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.