The Manager, Quality and Credentialing is responsible for providing oversight, daily administrative management, and direct supervision of the Quality Management and Credentialing teams. The Manager designs, modifies and/or proposes operational systems and processes to effectively and efficiently manage and coordinate the activities outlined within the departmental policies/procedures, the Quality Management and Credentialing Programs and Work Plans. The Manager will ensure consistent execution on performance improvement programs and initiatives including but not limited to HEDIS, Pay for Performance, CMS Star, and HCC coding. This position is also responsible and accountable for maintaining compliance with all contractual obligations, state regulations and NCQA standards for activities related to the areas of responsibility.
The Quality and Credentialing Manager is accountable for the oversight and coordination of the following major functions:
Quality Management Program Credentialing Program Performance Improvement Initiatives/Programs Complaints, Appeals and Grievances Medical Record and Site Review Health Promotion Continuity of Care Activities Medical Review/Peer Review
Current unrestricted LVN license is required. Current unrestricted RN license preferred.
Minimum of four (4) years combined previous clinical experience providing direct patient care and quality management, disease management or case management experience specifically related to Managed Care in a complex and diversified healthcare or health insurance company.
Minimum of two (2) years recent experience directly managing/supervising personnel.
Strong working knowledge of managed care related Quality Management and performance improvement concepts including Pay for Performance, HEDIS and CMS Stars, Including knowledge of CMS HCC Risk Adjustment and Coding guidelines preferred.
Well versed in regulatory standards pertaining to areas of responsibility (i.e. HIPAA, NCQA, DMHC, CMS)
Demonstrated computer skills; proficient with Microsoft Windows applications including but not limited to Excel, Word and Outlook as well as ability to conduct Internet based research. Familiarity with Microsoft Access and/or SQL a plus.
Experience in using provider credentialing management software i.e. Morrisey, CACTUS, HealthLine, Echo.
Familiarity with CPT, ICD-9/ICD-10, and HCPCS codes.
Sound and independent judgement and the ability to think and conceptualize beyond existing barriers, methods and practices.
Strong leadership skills, with the ability to articulate goals, plan and implement processes to achieve those goals, recognize and assess the implications of confounding variables, anticipate consequences, and meet deadlines.
Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardizations exist.
Effective oral, written communication and presentation skills sufficient to communicate clearly and grammatically both complex and simple messages to a wide audience either within or outside of the organization
Detail-oriented without losing sight of broader perspectives.
Reliable means of transportation; This position requires travel to meetings, conferences and trainings throughout the UCLA Health campuses as well as meetings held in off-campus locations.
Location/Region: Los Angeles, CA