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Quality Control Manager - Hybrid

Company: Tenet Healthcare
Location: Los Angeles
Posted on: November 19, 2023

Job Description:

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step! JOB SUMMARY The role of the Quality Control Manager is to provide oversight, daily administrative management, and direct supervision of the Quality control department. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned.

  • Manages the claims quality auditors and daily activities of quality claims audit function. Reviews and tracks claims quality audit reports and measures performance of auditors. Provides assistance in developing claims audit policies and procedures. May provide coaching in complex claims audit. Manages subordinate staff in the day-to-day performance of their jobs. Ensures that project/department milestones/goals are met. Has full authority for personnel actions. Extensive knowledge of department processes.
  • Responsible for insuring client deliverables are met related to the quality/compliance standards per current contract terms or SLAs. This may be accomplished by, but not limited to the following:
    • Coordinating daily workflow of auditing team to insure timely auditing of staff accounts
    • Distributing workload amongst auditors by allocating assignments according to client needs
    • Directing work priorities of direct reports and/or support staff to insure timely processing of claims and or project deadlines.
    • Provides input to strategic decisions that affect the functional area of responsibility such as
    • Claims department, Compliance and Quality Control department.
    • Develops a QC Plan that includes methods to measure, track, analyze, report performance trends, root cause analysis of deficiencies, implement corrective actions, and provide follow up.
    • Proactively identify opportunities for improvement to processes and scripts, responsible for reporting and documenting problems, concerns or any issues identified during the review process to Operations Excellence Committee and/or other Committees.
    • Audits system configuration for new client implementation and provider or Health Plan contracts and amendments.
    • Various administrative functions associated with the above duties include but are not limited to budget development and monitoring, performance evaluations, team meetings and huddles, interviewing/hiring new applicants, action plan development, corrective action, scheduling, coordinating internal and external quality reviews. KNOWLEDGE, SKILLS, ABILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
      • Strong knowledge and understanding of Managed Healthcare.
      • Excellent communication skills, written and verbal.
      • Must be well versed in reading Health Plan DOFRs and understand all types of fee schedules, including risk pools.
      • Excellent knowledge of CPT, RBRVS, DRG, HCPCS and ICD-9 coding and regulations.
      • Software: Microsoft Office, EZ-Cap, McKesson Claim Check, Redbook, DRG Pricing Software
      • Skilled in performing quality assessment/analysis
      • Skilled in formulating or writing scripts
      • Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
      • Must have strong interpersonal, written and verbal communication skills and management experience.
      • Ability to think/work independently yet interconnect with the team.
      • Advance problem-solving skills
      • Great attention to detail is crucial to this position Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. EDUCATION / EXPERIENCE Include minimum education, technical training, and/or experience preferred to perform the job.
        • Bachelor's degree or equivalent work experience required
        • High school diploma or equivalent required
        • 5 years or more experience processing managed health care claims preferred.
        • 5 years or more experience as Quality Control Sr. or Lead
        • Ability to manage all aspects of a team of on-site, remote and/or regional
        • Must possess extensive knowledge of different payment methodologies, compliance guidelines REQUIRED CERTIFICATIONS/LICENSURE Include minimum certification required to perform the job.
          • No certificate required PHYSICAL DEMANDS 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 may be made to enable individuals with disabilities to perform the essential functions.
            • Must be able to work in sitting position, use computer and answer telephone WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
              • Office Work Environment TRAVEL
                • Some travel may be required Compensation and Benefit Information Compensation
                  • Pay: $72,509-$108,763 annually. Compensation depends on location, qualifications, and experience.
                  • Management level positions may be eligible for sign-on and relocation bonuses. Benefits Conifer offers the following benefits, subject to employment status:
                    • Medical, dental, vision, disability, life, and business travel insurance
                    • Paid time off (vacation & sick leave) - min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
                    • 401k with up to 6% employer match
                    • 10 paid holidays per year
                    • Health savings accounts, healthcare & dependent flexible spending accounts
                    • Employee Assistance program, Employe discount program
                    • Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
                    • For Colorado employees, Conifer offers paid leave in accordance with Colorado's Healthy Families and Workplaces Act. 2305018808

Keywords: Tenet Healthcare, Los Angeles , Quality Control Manager - Hybrid, Executive , Los Angeles, California

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