SIHO Insurance Services
  • - Medical Management
  • Columbus, IN, USA
  • Full Time

Job Title:                    Clinical Quality Program Manager  

Location:                     Columbus, IN

Reports To:                Director, Medical Management

 

 

Job Summary

 

This is a full time exempt position reporting to the Director of Medical Management. The Clinical Quality Program Manager (CQPM) is responsible for coordinating quality improvement (QI) activities within the medical management department.  This individual plays an integral role in monitoring key organizational quality improvement indicators in the Medical Management (MM) Department, ensuring that QI indicators are documented and reported.

 

Key Responsibilities: 

 

  • Assist in monitoring compliance with all local, state, federal, and all accreditation standards and keeping the department updated
  • Assist and act as a resource to companywide quality improvement processes on behalf of medical management
  • ·         Act as a liaison between MM department and Pharmacy Benefit Manager(s) (PBM); monitor and maintain current guidelines for access and utilization by MM department.
  • ·         Act as a resource for clinical evaluation of Preventive Health Benefit (PHB) recommendations
  • Update and Maintain MM Department new employee training documents in compliance with all local, state, federal, and URAC /all current accreditation standards
  • Reports quality improvement initiatives and data
  • Coordinate and conduct quality improvement studies as indicated
  • Develop and implement QI audit, reporting and monitoring tools
  • Document, develop and monitor corrective action plans in response to audits
  • Develop and maintain medical, Wellness, and pharmacy Policies and Procedures (P&Ps) and MM Guidelines for Medical Management in compliance with all local, state, federal and URAC/all current accreditation standards
  • Maintain online master lists and folders of MM Guidelines, P&Ps and current Quality Improvement Projects (QIPs) with all relevant data for the purpose of meeting external and internal accreditation audits
  • Assist in monitoring and maintaining process controls for SSAE18
  • Attend SIHO Quality Management Committee (QMC) meetings quarterly and coordinate activities between MM and the committee
  • Investigate adverse occurrences and quality of care complaints
  • Assess opportunities for improvement and propose solutions across lines of business
  • Function as a role model and healthcare leader when working with all SIHO staff
  • Act as a resource to assess capabilities of all potential Utilization Management (UM) Contractors prior to delegation of services
  • Act as a resource to monitor functions of all delegated contractors
  • Perform Utilization Review (UR) as needed for quality assurance purposes
  • Demonstrates compliance with all SIHO policies and procedures; Employee Handbook statements on conflict of interest, protected health information and regulatory compliance

 

 

Minimum Skills, Education, Training Requirement:

 

  • RN with minimum of 5 years clinical experience
  • Current, unrestricted  Indiana RN license
  • NCQA or URAC experience preferred
  • Utilization Review experience preferred
  • Strong critical thinking skills, communication skills and documentation skills
  • Strong organizational skills
  • Ability to analyze statistical data
  • Working knowledge of managed care principles
  • Strong problem solving and decision making skills
  • Strong computer skills
  • Must be able to work independently

 

Other:

 

  • Confirmation of excellent attendance record
  • General knowledge and understanding of an office environment
  • Represent SIHO by participating (volunteering) in community activities

Stay current on all clinical certifications and other continuing education requirements




This position has been closed and is no longer available.
SIHO Insurance Services

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