Where You Will Be Working:
Medical Associates Clinic is a physician-owned multispecialty group practice. Our 100+ physicians and 900 health care professionals lead the way in providing superior healthcare and excellent patient experiences in Northeast Iowa, Southwest Wisconsin and Northwest Illinois.
Medical Associates Health Plans has served the employers and residents of the Tri-State area for over 35 years with fully insured health insurance products and a unique Medicare program. In addition, Medical Associates Health Plans offers administrative services to employers who self-fund their health insurance through its affiliated company, Health Choices.
Medical Associates Health Plans was established in 1982 by Medical Associates Clinic and was the Tri-State area’s first health maintenance organization. Our health plans are special and unique in the way we provide the best possible healthcare, the most careful coordination and communication, and the highest level of service to you as plan members and as patients.
What You Will Be Doing:
As a Quality and Access Care manager, you will assume overall responsibility for departments including Quality Improvement (QI), Central Prior Authorization (PA) and Patient Services (PTS) at Medical Associates Clinic and Health Plans.
Medical Associates is proud to provide the highest quality of care to our patients and health plan members. Our NCQA and CMS 5 star rating is proof of our continuous commitment by our quality improvement team to provide support and guidance to our contracted providers. By becoming part of our team, you will help coordinate clinical quality and patient safety measures consistent with accreditation guidelines and regulatory bodies. You will have the opportunity to work collaboratively with physicians, advanced practice providers, staff, and other healthcare professionals at Medical Associates and contracted network providers to educate on quality metrics, risk adjustment coding, optimal clinical workflow(s) to achieve the best possible outcomes for our patient population.
Our Central PA team is the backbone of our authorization process to allow for our forward-facing staff to focus on delivering the best care they can without having to be on the phone with insurance companies. As the leader of this department, you will support staff and be the liaison to the clinical and business staff at Medical Associates Clinic.
Medical Associates has provided 24-hour nursing support for Dubuque County for about 25 years. Community members rely on this service to avoid unnecessary emergency room visits. In the past couple of years, we have expanded this service to other communities to bolster the clinical efforts in their counties. As part of the team, you will be able to grow and strengthen the existing communities being served.
Schedule:
As a general leadership position, core business hours for this position are Mon-Fri, 8-5:00 with flexibility to attend to meetings and duties outside core business hours on occasion.
Strong Compensation Package and Benefits worth $20,000!
- Health Insurance and Flex Spending Accounts
- 401K Matching & Profit Sharing
- Generous Paid Time Off (PTO)
- Life Insurance and Short Term Disability (STD)
What Skills You Bring:
- RN degree and valid RN license, BSN Preferred
- 3-5 years experience and general leadership experience preferred
- Strong organization skills, multitasking, and follow-through
- Solid interpersonal skills and ability to work collaboratively and lead effectively while influencing positive change
Essential Functions & Responsibilities:
- Review, interpret and implement regulatory changes that are required for National Committee for Quality Assurance (NCQA), Healthcare Effectiveness and Data Information Set (HEDIS), Accountable Care Organization (ACO) and Center for Medicare and Medicaid Services (CMS) star ratings for each reporting year. Educate Medical Associates Health Plans (MAHP) staff, physicians/advanced practice providers and other applicable healthcare professionals on these metrics/standards to help optimize patient health outcomes and enhance patient experience. Regularly monitor and provide analysis of quality improvement and initiative efforts. Ensure development or revision of policies and procedures, physician practice guidelines and other supportive material to meet regulatory changes. Develop and manage the QI work plan for Medical Associates Clinic (MAC) and MAHP. Provide direction and strategies to direct reports related to process change for quality initiatives, risk adjustment coding opportunities, patient satisfaction initiatives, and problem resolution. Provide supervisory support for annual HEDIS submission including Interrater Reliability maintenance, auditing support and education, onsite review and vendor contracting. Lead bimonthly QI Committee meetings, coordinate agendas, monitor follow-up action plans and communications. Participate in Primary Care Quality Meeting and other meetings as assigned. Provide direction to the Quality Improvement Coordinator to assist in managerial support of the department.
- Plan and implement the overall nursing policies, procedures and services for the MAC/MAHP Patient Services 24-hour nurse line. Ensure consistent use of standardized protocols in providing advice to patients and members of MAC and MAHP along with all other health systems that the PTS department supports. Ensure adequate resources are available to staff to provide accurate and concise advice. Maintain and implement changes to the documentation system used by staff. Establish Electronic Medical Record
access as needed to support communication between PTS staff and providers. Assist with the strategic development of expanding the PTS support to other Health Systems including staffing, technological support, protocol adjustments and any other identified needs. Support back up assistance for claims review and authorization by PTS nursing staff for Central PA and MAHP authorizations. Provide direction to the PTS Coordinator to assist in managerial support of the department.
- Channel all patient feedback and complaints to appropriate staff and facilitate response to patients. Manage the patient incident process through investigation, reporting and corrective action, involving the Counsel & Compliance Manager as necessary. Provide trending information for complaints and incidents to Director of Quality and Healthcare Services.
- Provide direction, oversight and back up assistance for the Central PA staff. Ensure timely reviews are completed by staff by monitoring outstanding fax and Cerner tasks. Provide assistance and problem resolution to outside departments with regard to the prior authorization process. Assist staff with the appeal process and setting up peer-to-peer reviews.
- Manage hiring selection, training, scheduling, development, performance evaluation, and performance issues for direct reports. Provide oversight of the day-to-day activities and ensure appropriate staffing levels are maintained to deliver high quality and adequate provider/member/patient services for all direct report departments. Implement changes to effect continual improvement in services provided and ensure high level of quality consistent with organizational standards. Ensure that staff are current in competencies, licensure, certifications and other annual training. Ensure compliance with departmental policies and procedures by providing direct guidance in their interpretation.
- Provide support to providers/office staff for portal access and authorization submissions. Facilitate internal audits to ensure accuracy of authorization requirements in claims system, medical necessity decision making as well as tertiary referrals for all lines of business. Assist with claim reviews for medical necessity and work with MAHP claims and configuration staff to improve throughput. Manage and ensure timely response to denial and appeal requests for all MAHP lines of business ensuring that all regulatory standards are being met.
- Collaborate with MAC and MAHP Departmental Managers, Clinical Applications Support and Training Team to establish and/or improve clinical workflows to ensure quality metrics standards are being met. Participate in quality initiatives and meeting with departmental teams.
- Complete all other assigned projects and duties.
Knowledge & Skills:
Education: Valid RN nursing degree and license. BSN preferred.
Experience: Three years to five years of similar or related experience.
Interpersonal Skills: The ability to motivate or influence others is a material part of the job, requiring a significant level of diplomacy and trust. Obtaining cooperation (internally and/or externally) is an important part of the job.
A significant level of trust and diplomacy is required, in addition to normal courtesy and tact. Work involves extensive personal contact with others inside and/or outside the organization, and/is usually of a personal or sensitive nature. Work may involve motivating or influencing others.
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