- Perform duties to direct and coordinate the medical management, quality improvement and credentialing functions for the assigned health plan based on, and in support of the company’s strategic plan; establishing the strategic vision and attendant policies and procedures.
- Direct and coordinate activities of department and aid the chief officer of the health plan and appropriate corporate staff in formulating and administering organizational and departmental policies.
- Review analyses of activities, costs, operations and forecast data to determine department progress toward stated goals and objectives.
- Serve as a member of management committees on special studies.
- Administer and ensure compliance with National Committee on Quality Assurance (NCQA) and/or Joint Commission on Accreditation of Healthcare Organization (JACHO) standards as determined for accreditation of the health plan.
- Participate in, attend and plan/coordinate staff, departmental, committee, sub-committee, community, State and other activities, meetings and seminars.
- Participate in provider education and contracting, as necessary.
Education/Experience: Bachelor's degree in Nursing, related field or equivalent experience. 10+ years of clinical nursing, quality improvement, and management experience in a managed care setting. Thorough knowledge of a specialized or technical field such as clinical nursing, managed care, and healthcare administration. Thorough skills knowledge of quality improvement practices. Working knowledge of medical information systems, medical claims payment process, medical terminology and coding, case management practices, managed care, and Medicaid programs. Familiarity of National Committee on Quality Assurance (NCQA) accreditation process and standards. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
Current state nursing license.
PA Plan Only: State license required within 90 days of hire