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Overview

Overview

To develop and implement long-term quantitative analysis strategies to meet NCQA standards for reporting. Identify quality gaps, implement reporting processes in order to track grievances concerning access to care,  appeals trending, enhance current systems, define and prioritize high-value quality products and manage regulatory reports to completion. Develop standardized testing methods which facilitate the quality checking process.

Responsibilities

  • Develop quantitative analysis and reporting for grievances and appeals to meet NCQA, DHCS, and other regulatory standards.
  • Define and implement an overall quality strategy and approach to determine, investigate, and resolve data quality issues with regulatory reporting for grievances and appeals.
  • Utilize profiling, quality tools, and various data sources in order to determine causes of quality issues.
  • Establish an on-going process to maintain quality data and define quality audit processes.
  • Identify and leverage opportunities to improve the quality management processes, systems, and standards. –
  • Work closely with Regulatory Affairs/Compliance and internal business units to resolve any regulatory report quality issues. –
  • Recommend modifications and changes, if any, to the appropriate departments.
  • Other duties as assigned.

Qualifications

Education and Experience Bachelor’s degree in Computer Science, Quality Control, Quality Assurance, or related field preferred. Two (2) years quality administration related activities.

 

Special Skills, Licenses and Certifications Demonstrated aptitude for acquiring and applying technical skills in data analysis, reporting, and data systems. Good oral and written communication skills. Strong analytical skills including knowledge of statistics. Excellent interpersonal skills. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

 

Performance Based Competencies Knowledge of MS Excel, Access, Tableau and other analytic software. Demonstrated aptitude for acquiring new technical skills in a data quality environment. Familiar with quality measurement and healthcare data. Ability to communicate technical concepts with both technical and non-technical individuals. Detail-oriented with good organizational and project management skills to work on multiple projects simultaneously within established time frames.
Work Environment And Physical Demands Standard cubicle within a shared common area. Ability to use a computer with standard software packages. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, and/or lift objects of varying size, weighing up to 25 pounds.

All HealthPlan employees are expected to:

  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Minimum Education and Experience

Minimum Months of Experience: 24
Education Required: Bachelor's
Driver's License Required: Yes
Hiring Requirements for this Job:
  • Drug Testing / Screening
  • Background Checks