The Director will lead all quality initiatives for the IN plan. In addition to managing their staff, you will use your past experience with an NCQA accredited plan to fine tune processes and attain NCQA accreditation. Also included in your responsibilities are the following:

- Provide leadership and direction for the Quality Department
- Perform duties to oversee and manage the functions of the quality improvement program
- Provide support to staff and communicate with departments and staff to facilitate daily quality improvement (QI) functions.

Leadership: Manage and coordinate activities of the assigned work function and/or department. Assign or delegate responsibilities for specific work or functional activities. Give work directions, resolve problems, prepare schedules and set performance expectations and deadlines to ensure timely completion of work. Coordinate activities of assigned work function and/or department with related activities of other work functions and/or departments to ensure efficiency and economy. Report Preparation: Review and analyze reports, records and directives, and confer with staff to obtain data required for planning work function activities, such as new projects, status of work in progress, and problems encountered. Also to verify data to be submitted in accordance with state Medicaid program requirements and to ensure compliance with Company, Federal, State, Health Plan Employer Data and Information Set (HEDIS), National Committee on Quality Assurance (NCQA) and/or Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards. Prepare reports and records on work function activities for management, using computer. Methods and Procedures: Evaluate current procedures and practices for accomplishing the assigned work function’s objectives to develop and implement improved procedures and practices and to ensure compliance with Company, Federal, State, National Committee on Quality Assurance (NCQA) and/or Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards. Customer Service: Collaborate with appropriate departments to document, investigate and resolve formal/informal complaints and appeals in accordance with Company and State policies, procedures and requirements Annual Budgeting: Monitor and analyze costs and participate in the preparation of the budget, using computer. People Development: Initiate and participate in the hiring of staff, promotions, discharges and transfers. Train and supervise staff. Typical Duties: Participate in, attend and plan/coordinate, as necessary, staff, departmental, committee, sub-committee, State and other activities, meetings and seminars.

Responsibilities include part patient care/floor and part Operations/Management. Ideal candidate would be a Charge or Supervisor looking to step into a teaching role. Will report to the DON.

Assists the nursing staff in the assessment planning implementation and evaluation of nursing care for patients in accordance with established policies and procedures.

Communicates all pertinent information concerning patient care for the assigned patient population as directed.

Accountable for monitoring continuous quality improvement activities related to the assigned patient population and the development of standards of care and practice.

Review inpatient admissions to assure appropriate level of care and medical necessity.
Review admissions through on-site and telephonic review to ensure medical necessity and appropriate level of care. Act as clinical resources to referral staff and make appropriate referrals. Provide patient and provider education. Data enters assessments, authorizations and reviews into the system. THIS position will work partially in the office and partially on-site at the hospitals.

Perform utilization review for outpatient services. Review prior authorization requests utilizing approved criteria/guidelines to ensure the medical necessity of requested services/procedures.
Gather, collect, and document information necessary for the review of prior authorization requests received via fax or telephone from providers into designated systems according to procedure.
Refer cases not meeting criteria/guidelines for physician review. Communicate review outcomes to providers per protocol. Act as a clinical resource to referral staff. Provide patient and provider education.

Review and analyze reports, records and directives.
Confer with staff to obtain data such as new projects, status of work in progress, and problems encountered, required for planning work function activities. Verify data to be submitted in accordance with government program requirements and ensure compliance with state, federal and certification requirements.
Prepare reports and records on work function activities for management.
Oversee the review and analysis of reports.
Evaluate current procedures and practices for accomplishing the assigned work functions objectives to develop and implement improved procedures and practices and to ensure compliance with required standards.
Collaborate with appropriate departments to document, investigate and resolve formal or informal complaints and appeals in accordance with Company and State policies, procedures and requirements.
Monitor and analyze costs and participate in the preparation of the budget.