Keystone Peer Review Organization, Inc. Looking for Quality Manager (RN) – Remote at Jackson, Wyoming Full Time

Quality Manager (RN)

• Are you an experienced Quality Manager looking for a new challenge?
• Do you value care management and quality improvement?
• Are you motivated, energetic, and excited to become part of the Kepro team?

If so, you might be our next new team member!

Who we need:

The Quality Manager (RN) is a registered nurse and is responsible for developing, implementing, and monitoring quality and performance improvement activities and clinical outcomes for the commercial department, supporting both medical and behavioral health.

Why us?

Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

People Focused. Mission Driven.

Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

We do this through our people.

At Kepro, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

Benefits are a key component of your rewards package at Kepro. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

What you’ll do:

• Leads and facilitates all Quality and Performance Improvement (QPI) activities, relative to Kepro’s commercial contract department
• Provides QPI coaching to managers and Kepro staff
• Ensures the implementation of key performance indicators and maintains systems for tracking, reporting, and improving performance.
• Assists operational leadership in developing benchmarks for quality measures and outcomes over time and across programs.
• Facilitates electronic access for Kepro commercial operations staff to current and archived policies, procedures, job aids, letters, reports, committee agendas and minutes. Responsible for ensuring all are updated as changes occur or at least annually.
• Ensures the promotion of awareness of customer requirements (Service Level Agreements) throughout the operation.
• Supports and participates in existing CQI activities, quality/outcome studies and the development of cutting-edge innovative programs
• Leads the Local Quality Improvement Committee (LQIC) and participates in KEPRO’s Clinical Practice Oversight Committee (CPOC).
• Supports quality of care reviews, investigates, and assists in resolution of member grievances or complaints about employees.
• Monitors to ensure that Kepro staff have appropriate credentials and training commensurate with their job description. Discrepancies are communicated to applicable leaders.
• Conducts audits of Utilization and Case Management cases and reviews manager’s audit results to confirm compliance with URAC and other regulatory documentation requirements
• Monitor and report on specified quality indicators to identify opportunities for process improvement. Identifies areas of potential risk associated with the findings.
• Develop and maintain Quality Improvement Processes (QIPs) in alignment with URAC requirements.
• Leads evaluations of program effectiveness
• Documents quality metrics in corporate database; identifies positive and negative trends; shares findings with department leadership.
• Reviews member satisfaction surveys, and provides comparison to performance indicators.
• Reviews, evaluates and reports critical incidents to corporate compliance (ie. data/ HIPAA breaches, etc.) which may have immediate negative implications for the Company and assists with the formulation of a plan of action for handling the incident/issue.
• Executes CQI plans to ensure they meet current and future business requirements (e.g., best practices, quality, work efficiencies, regulatory requirements, & new program introductions).
• Participates in preparing and submitting quarterly and annual quality reports and/or deliverables to commercial clients
• Identifying patterns and trends in clinical case and utilization management performance and outcomes.
• Responsible for maintaining the Department’s Quality Management Plan and Program Description.
• Coordinate with Subject Matter Experts (SMEs) in developing clinical solutions that support achieving desired outcomes
• Focus on clinical outcomes, supporting operations with the following:

o Evaluating UM and CM programs to include modifying assessments and care plans to best capture reportable outcomes

o Work with leadership, commercial operations and analytics to identify UM and CM program value components;

o Converting outcomes metrics into meaningful client reporting

o Adjusting clinical program referral triggers to support population changes in diagnosis trends

o Analyzing operational data to include comparing against benchmarks and, in conjunction with leaders, recommending program/policy changes based on trends

• Support commercial implementations to ensure successful go live for clients
• Support RFP and Proposal processes for commercial clients

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

What you’ll need:

Required Qualifications

• Active unrestricted nursing license, or other applicable State and/or Compact State clinical licensure required.
• Bachelor’s degree in nursing required.
• Formal training or certification in quality desired (CPHQ, ISO, Six Sigma)

Knowledge, Skills, Abilities

• Knowledge of performance improvement strategies, principles, methodologies, techniques and data analysis
• Ability to take initiative, provide leadership, maintain confidentiality, meet deadlines and work in a team environment.

• In depth knowledge of CQI tools, methods and techniques such as Six Sigma
• Excellent grasp and understanding of SPC (Statistical Process Control).

• Knowledge of URAC, NCQA &/or ISO background a plus.
• Analytical skills must be highly developed with an ability to objectively evaluate data and perform statistical analysis.
• Knowledgeable in applying InterQual (Change) criteria, MCG, summary plan design and contract policy requirements.
• Excellent communication (verbal and written), organizational, presentation, and interpersonal skills required.
• Ability to prioritize and manage multiple assignments.
• Proficient in MS Office applications and internet/web navigation

Experience

• Quality management experience in a health-related field, required.

• Solutioning, recommending appropriate improvements and problem solving of various types of utilization and case management programs, required
• Minimum of 2 years case management experience, required
• Minimum of 1 year utilization management experience, preferred
• Experience with commercial health plans and/or clinical programs, preferred.

Thank You!

We know your time is valuable and we thank you in advance for applying for this position. Due to the high volume of applicants we receive, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Kepro and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Kepro Talent Acquisition Team

Mental and Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability

Kepro is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.