Payers & Providers California Edition – Issue of December 1, 2011

8/3/2019 Payers & Providers California Edition Issue of December 1, 2011

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Payers & Providers Page 2

Top Placement...Bottomless Potential

Advertise Here

(877) 248-2360, ext. 2

In Brief

Primes Billing ForHeart Failure Examined

Chino Valley Hospital has allegedlybeen billing Medicare to treatpatients for heart failure at rates farhigher than the national average,

according to a recent report byCalifornia Watch.

According to analysis of billingdata for Chino Valley, nearly one-third of its Medicare patients inrecent years suffered from acute heartfailure--a rate nearly six times theaverage for California. The facility isowned by Ontario-based PrimeHealthcare Services.

California Watch, a non-protinvestigative journalism organization,noted the hospital billed Medicare forvirtually no heart failure patients in2006, just prior to Medicare initiatinga rule change that allowed a bonusfor treating such cases. Between 2008

and 2010, the hospital treated nearly2,000 patients for the ailment. Eight-eight percent of the time, thediagnoses was billed in a way thatwould trigger the extra payments.

Prime ofcials disputed thereport by California Watch, whichhas been scrutinizing Prime's billingpractices. Anthony Glassman, aPrime attorney, told the organizationits analysis was "faulty, unfair andbiased." He added that Chino Valleytreated such a large number of heartfailure patients because many areadmitted from nearby nursing homesand through the hospital's emergencydepartment.

Blue Shield Sends OutPolicholder Credits

San Francisco-based health plan BlueShield of California has begundistributing credits to itspolicyholders that range from 18% to54% of a monthly premium.

Continued on Page 3

NEWS

As Sacramento-based hospital system SutterHealth faces litigation over a breach ofpatient data involving 4.2 million patients itdisclosed last month, a new study of hospitalsystems indicates that the situation involvingcompromised medical data is getting worse,not better.

The study of 75 healthcare systems bythe Michigan-based Ponemon Instituteconcluded that healthcare data breachesincreased 32% in 2011 compared to 2010.The average cost of such a breach is morethan $2.2 million up around 9% from ayear ago. It also damages the brand of thehealthcare institution where the breachoccurs and leads to lost patients.

In California, 19 healthcareorganizations reported breaches to the U.S.Department of Health and Human Servicesin 2010, compared to 12 so far in 2011.

Of such breaches, 49% involved a lost or

stolen computing device, as was the case wthe Sutter incident. Thats up from 41% in2010.

Ponemon Institute Chairman LarryPonemom indicated that safeguarding suchdevices particularly smart phones will beone of the biggest challenges facing healthcorganizations in 2012.

Folks in the study have conceded that(portable devices) are not secure, saidPonemon. Another challenge is safeguardingdata as its transferred from paper to electronformat.

Sutter disclosed the breach last month,which occurred as the result of the theft of adesktop computer. The device was passwordprotected but not encrypted.

Law rms in Los Angeles and Sacramenled class-action suits last week against SuttOne of the suits seeks more than $4 billion damages.

Patient Breaches Continue To GrowLittle is Done to Address Portable Device Security

Continued on Next Page

Thursday, Dec. 15, 2011 10 A.M. P

California Healthcare: A 2012 Business Forecas

Please join Steven T. Valentine, President of The Camden Group, Henry R. Loubet, Chief StrateOfficer for Keenan, and Jim Lott, Executive Vice President of the Hospital Association of SoutherCalifornia, to discuss the trends that will shape California!s healthcare business environment in 20

http://www.healthwebsummit.com/ppcalifornia121511.htm

a HealthcareWebSummit Event co-sponsored by PAYERS & PROVIDE

CHA Tries To Enjoin Medi-Cal CutsMotion on Matter Will Be Heard Later This Month

The California Hospital Association is seekinga federal court injunction against pendingreductions in Medi-Cal payments it believeswill seriously damage its constituents.

The motion for an injunction, which willbe heard in Los Angeles on Dec. 19, comes astrade groups representing physicians, dentistsand pharmacists led their own suits againstthe Department of Health and HumanServices and the California Department ofHealth Care Services for cuts in Medi-Cal

reimbursement expected to affect theirpractices. The reductions, which range from10% to more than 20%, are retroactive to Ju1 and were recently approved by the federagovernment. If enacted, they would save theMedi-Cal program about $623 million peryear.

During months of conversations withstate and federal ofcials, hospitals across
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Page 3Payers & Providers

Longer ALOS!*

Advertise Here

(877) 248-2360, ext. 2

*For our ads, not your hospital

NEWS

In Brief

Blue Shield announced thecredits earlier this year as part of apledge to limit its net income to 2%of its annual revenue. Blue Shield is anot-for-prot organization.

As a mission-based, not-for-prot health plan, we made thiscommitment to help keep coverage

affordable for our members. Whilethese credits will help our customers,every player in the healthcareindustry must do more to reduce thecost of care, said Blue Shield ChiefExecutive Ofcer Bruce Bodaken.

The average credit for anindividual plan enrollee is $135, witha family of four receiving about $420.Large and mid-sized group customerswill receive credits ranging from $195to $235 per enrollee, with smallgroups receiving an average of $220.

UCLA Nursing School

Intervention ProgramGets Federal Funding

The U.S. Department of Health andHuman Services has chosen forfunding a program started by theUCLA School of Nursing that targetsminority teenagers who have givenbirth or are pregnant.

The Public Health Nursing EarlyIntervention Program for AdolescentMothers provides education forexpecting Latina and African-American teen mothers regardingprenatal healthcare, childbirth andpreparation for motherhood. The

intent is to cut down on healthcarecosts for their newborns, many ofwhich have low birth weights andother problems often requiringhospitalization.

The costs to the U.S. healthcaresystem are substantial about $9billion each year so it is in theinterest of the states to enhance thehealth outcomes for those teens whodo become pregnant and for theirbabies, said Deborah Koniak-Grifn,a UCLA nursing professor anddirector of the universitys Center forVulnerable Populations Research.

HEALTHCARES BEST ADVERTISING VALU]

PAYERS & PROVIDERS reaches 5,000 hospital, health plan and noprot executives statewide. There is no better venue for marketin

your organization or conference, or recruiting new staff.

CALL (877) 248-2360, ext. 2OR CLICK HERE

Kaiser Enters Breast-Feeding PactInitiative Expected to Fight Childhood Obesity

Healthcare system Kaiser Permanente hasentered into a pact with the Partnership fora Healthier America to signicantly rampup the number of children born at itsfacilities who breastfeed.

The initiatives aim is to reduce theskyrocketing rates of childhood obesity.Nearly 20% of American children areconsidered obese, a rate that has tripledover the past 30 years.

Although breast-feeding a child during

therst year of life is linked by someresearch to lower rates of obesity, only

13% of children are still being breast-fedwithin six months of birth, according to theU.S. Surgeon Generals ofce, whichblamed the trend in part on poor planningby hospitals. Barriers to breastfeeding arewidespread during labor, delivery, andpostpartum care, as well as in hospitaldischarge planning, read a SurgeonGenerals report issued in January.

Under the agreement, Kaiser said byearly 2013, all of its hospitals that offer

maternal services would either bedesignated as baby-friendly based oncriteria provided by the Baby FriendlyHospital Initiative, or participate in theJoint Commissions perinatal coremeasures program. That requires eachhospital to report breastfeeding rates atdischarge. Those rates will also be inclin Kaisers quarterly quality scorecard.Fewer than half of Kaisers hospitals nohave the baby-friendly designation.

Kaiser could not provide specic don what percentage of children born a

facilities leave breastfeeding. Californione of the higher rates of breastfeedingchildren in the U.S.

"Kaiser Permanente's commitmentmake breastfeeding a priority for each born in one of their hospitals has potento make a very big impact, said LawreA. Soler, chief executive ofcer ofPartnership for a Healthier America. Wpleased they are such a strong partner ghting childhood obesity."

California provided compelling evidenceabout the impact these cuts will have onaccess to care for our most vulnerable

patients, said CHA President C. DuaneDauner. We believe that the cuts are inviolation of federal Medicaid law andwithout regard for the welfare of thousandsof patients with complex medical needs.

The CHA, which led suit against thestate and federal government last month,wants to block rate cuts for skilled nursing

facilities operating within hospitals. Accordingto a recent survey of its membership, halfwould close their skilled nursing facilities,

while more than a third are ponderingreducing beds or closing such services toMedi-Cal enrollees.

In addition to the CHA suit, the CaliforniaMedical Association, California DentalAssociation, California PharmacistsAssociation and the National Association ofChain Drug Stores sued late last month.

CHA (Continued from Page One)
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Payers & Providers PageOPINION

Employers As Tough Benefit ManageLittle Attention is Paid to Making Coverage Perform

Cyndy Nayer is president and chief exec

of the Center for Health Value Innovation.

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Op-ed submissions of up to 600 words ar

welcomed. Please e-mail proposals to

[email protected]

Healthcare is like no other U.S. industry.Employers do not manage their health costslike they do every other supplier or vendor;youd be hard pressed to nd another examplewhere companies pay millions of dollars forservices without requiring quality or evenresults, for that matter. As one of the largestpurchasers of healthcare, employers must takeresponsibility to combat rising costs and poorquality by demanding and measuring qualityand value for every dollar spent with theirvendors (i.e. health plans and providers).

According to recent research released bythe non-prot Center for Health

Value Innovation (CHVI),healthcare benets are under-managed. A focus on outcomes missing from most benet programs-- could produce better results.

CHVIs efforts over the past veyears have conrmed thatengagement and accountability aresorely lacking across all of thestakeholders in the health supplychain, including consumers,employers, providers and healthplans. Payment reform has beenpromoted to manage the rising costsof inpatient and outpatient services,and outcomes-based contracting(aligning incentives across allstakeholders) has taken a major stepforward to align payment with metrics thatmatter (adherence to safety and clinicalguidelines, for example). Outcomes-basedcontracting puts a part of a service agreementat risk and then uses benet design incentivesto drive patients to the higher-performingservice providers, improving engagement andaccountability.

Many employers spend millions of dollarson healthcare without understanding theirengagement and outcomes patterns. In theseall-too-common scenarios, healthcare servicesare purchased on a rate per employee. Forinstance, medication coaching may bepurchased for $10 per diagnosed employee formanagement of diabetes. (Numbers here areused only for illustration and not related toactual costs.) If there are 100 diagnoseddiabetics in the population, then theemployers pay 100 times $10, or $1,000.

Yet who is managing the deliverables? Insurveys and seminars I have led for over 15

years, employers often tell me that less tha10% or even 20% of their targeted populais engaged in these programs.

Translated to common purchases, banaare sold at about $1 a pound and there aretypically four bananas in a pound. If you p$1, you expect four bananas. What if you received one banana? Would you want arefund? Would you want the grocer to go risk to guarantee you get the bananas? Wthis not the case for healthcare?

Even acknowledging that some folks wnever engage, you might expect 75%

engagement in the programs. Per

we could be comfortable with tof the four bananas. But todayemployers are often settling for return of only one or two banan

This lack of oversight leads tosignicant waste. Employers areworn down from the past severayears of economic turmoil, the fof changing insurance plans orbenets advisers during the heareform ramp up, and thedownsizing of benets staff at mcompanies.

Employers must begin to take more active and disciplined riskmanagement approach for healthbenets. Employee health screenshould be their rst step. After th

employers should offer guidance to emploon the goal-setting and tracking of prescribtreatment; build accountability throughoutcomes-based contracting by creating aprototype contract for services, data andmeasures; and identify and implement bespractices that improve accountability foroutcomes.

We must treat employee benets andhealthcare expenses like any other businespractice. We need to align responsibilitiescontrol healthcare and absence costs in a wthat encourages good performance and gohealth.

ByCyndy Nayer


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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

It costs up to $27,000 to fill a healthcare job*

will do it for a lot less.

Employment listings begin at just $1.65 a word

Call (877) 248-2360, ext. 2Or e-mail: [email protected]

Or visit: www.payersandproviders.com

*New England Journal of Medicine, 2004.

SENIOR NETWORK CONTRACT MANAGER

UnitedHealthcare Employer & Individual is actively seeking a

Senior Network Contract Manager to join our team. The SeniorNetwork Contract Manager develops the provider network(physician groups and hospitals) yielding a geographicallycompetitive, broad access, stable network that achievesobjectives for unit cost performance and trend management, andproduces an affordable and predictable product for customersand business partners. Senior Network Contract Managersevaluate and negotiate contracts in compliance with companycontract templates, reimbursement structure standards, andother key process controls.

Specifically the Senior Network Contract Manager will:Formulate and execute contracting plans using financial modelsto meet or exceed established targets. Negotiate financial termsand contract language for capitated and fee-for-service medi-cal group and hospital agreements. Provide contract languageinterpretation as needed for related departments. Identify solu-tions to challenging issues, working with other departments tobring matters to resolution.

Qualified candidates please apply online athttp://careers.unitedhealthgroup.com,

Job number: 360202

CHIEF MEDICAL OFFICER

Inter Valley Health Plan, a regional Medicare Advantage Plan headquar-tered in Pomona, has an opening for a Chief Medical Officer. Reporting tothe President and Chief Executive Officer with dotted line reporting to theVice President, Health and Member Services, the Chief Medical Officer isresponsible for the design and implementation of clinical systems, strate-gies and initiatives to continuously improve the quality of patient careprovided to members by medical staff. As a key member of the executiveteam, the Chief Medical Officer will oversee clinical business strategies forthe health plan while establishing the highest standards of best practices.Responsibilities also include providing leadership and direction in clinicalintegration, education and medical staff development as well as oversee-ing the development, implementation and monitoring of Health Plan qual-ity and Utilization Management programs. Requirements Include: M.D.or D.O license in California with Board Certification in Internal Medicine;Masters degree in Public Health or related area a plus; Experience inManaged Care with an emphasis on Medicare and IPA ManagementProvider systems; demonstrated successful experience with managingUM, QM, and Credentialing areas; demonstrated strong leadership andmanagement skills with ability to employ sound reasoning and resource-

fulness to accomplish company objectives.

To Apply: Please submit resume with cover letter to: [email protected]; fax: 909-622-9634.


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

CLINICAL PHARMACIST

(Long Beach, CA)

JOB SUMMARY: Work in collaboration with the pharmacy staffto update and maintain the formulary used by SCAN. Spearheadand oversee the implementation of key clinical pharmacy programs.Work with appropriate departments to produce pharmacy relatedmarketing materials in accordance with CMS guidelines.

ESSENTIAL JOB RESULTS: Produce marketing materialswithin internally determined timeframes with accuracy and inaccordance with the CMS marketing guidelines. Utilize CMSmodel templates to populate pharmacy specific information

per CMS guidelines; partner with Marketing, Compliance andMember Education as needed. Work in collaboration withother pharmacy staff to support the annual formulary/ priorauthorization (PA) criteria submission to CMS. Prepare mono-graphs & prior authorization/ non-formulary exception criteriaand present clinical data on new drug therapies and clinicalprograms at Pharmacy and Therapeutics Committee meet-ings. Review new drugs with the Pharmacy & TherapeuticsCommittee within 90-180 days of being marketed. Decisionsrelated to the drug formulary and utilization managementrestrictions will reflect compliance with CMS guidelines.Develop and update Prior authorization criteria by using appro-priate clinical references when new clinical information becomesavailable. Coordinate the implementation of new and revised

PA/non-formulary exception criteria with the PBM company.Develop and/or implement clinical pharmacy programs in-houseor in collaboration with the Pharmacy Benefit Management(PBM) company as needed. Daily interactions with SCANemployees and/or PBM representatives may be required.

In-depth knowledge of CMS guidelines related to the ClinicalPharmacists job and the ability to ensure compliance with theCMS requirements is essential. Maintain professional and techni-cal knowledge by attending educational workshops; reviewingand contributing to professional publications; establishing per-sonal networks; participating in professional societies. Contributeto team effort by accomplishing related results as needed.

QUALIFICATIONS: Pharm.D. Degree with a residency programin Drug Information or Geriatric Pharmacy preferred. PharmacyLicensure in California required. Part D experience preferred.Managed care experience at a PBM, health plan or medical grouppreferred. Excellent verbal and writing skills required. Proficientin MS Office.

FT position, M-F 8 AM to 5 PM, occasional extended workhours as needed. Telecommute up to 25%. Apply towww.scanhealthplan.com - Job Opportunities - Req # 11-285

DIRECTOR, PHARMACY CLINICAL SERVICES

(Long Beach, CA)

JOB SUMMARY: Reporting to VP of Pharmacy Services, thisposition will play a central role in pharmacy management fora senior-focused Medicare Advantage Plan with over $140million in annual drug expenditure. Director will be account-able for providing leadership support to department, manag-ing change, improving efficiencies and managing and ensuringstrong clinical programs aligned with organizational direction.In addition, Director will service as Part D pharmacy expertfor the department and organization.

ESSENTIAL JOB RESULTS: Serve as a clinical/sub- ject matter expert on pharmacy benefit management.Coordinate the work product of clinical operation teammembers (clinical pharmacists and pharmacy benefitsadministrators). Oversee PBM operations to ensure highservice level to SCAN and our members. Oversee clinical andtechnical initiatives (eg. MTM, e-prescribing, provider/mem-ber web based tools). Monitor, evaluate, develop and imple-ment quality initiatives (i.e. DUR programs) and drug costmanagement strategies. Serve to oversee clinical operationsof pharmacy department to ensure proper accuracy and effi-ciency. Serve as backup of clinical operations when neces-sary (Grievances, appeals, medication therapy managementreviews, formulary management). Participate in business

and budget planning process. Oversee pharmacy operationsfor Employer Group Retiree Plans. Lead department initia-tives. Foster strong relations with internal departments andexternal providers. Serve as pharmacy expert on a varietyof committees and workgroups. Maintain current knowl-edge of Medicare Part D regulations by participating in CMScalls and reading released guidance.

QUALIFICATIONS: California State Board of Pharmacy,Registered Pharmacy license required. Doctor of Pharmacy(Pharm. D.), with residency in clinical pharmacy practicepreferred. Five (5) years or more of managed care phar-macy experience as a Director; or equivalent experience ina managed care setting, strongly preferred. Demonstrated

knowledge of Medicare Part D required. Medicaid knowledgepreferred. Excellent written, oral and interpersonal com-munication skills required. Strong computer skills using MSWord, Excel and PowerPoint required. Strong leadership &supervisory skills required. Strong analytical, problem-solving,negotiation, and decision-making skills required.

FT position, M-F 8 AM to 5 PM, occasional extended workhours as needed. Apply to www.scanhealthplan.com - JobOpportunities Req # 11-375


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Page 7Payers & Providers MARKETPLACE/EMPLOYMENT

DIRECTOR, MEDICARE

This position is responsible for the oversight and management of theMedicare Special Needs Plan and will work cross-functionally withinthe organization and externally on all issues related to Medicare.The position will also provide leadership on Medicare staffing andfunctions, organizational structure, and operational standards.The position requires an individual with Medicare operations andoversight experience, preferably who also has experience with dualeligibles or Medi-Cal. A Masters degree in Business Administration,Public Health, Public Policy, or related field is preferred, plus 2years experience and/or training. A minimum of 2 years of recentMedicare Advantage Part D plan experience is required.

MANAGER, HEALTHCARE ANALYTICS

This position is responsible for the oversight and management ofanalytical staff and the implementation of systems and techniquesfor analysis and reporting. The position requires an understandingof business needs, informational systems, healthcare data inputsand operations to ensure data quality and completeness in supportof analysis and reports that improve the quality and efficiency ofclinical and business processes and performance. The position willwork with key internal staff and outside business users to developthe functional and architectural design of data systems and datawarehouses and to select reporting tools that will enable easierend user access to data. A Bachelors degree or equivalent trainingin a health-related, scientific, or public policy/business discipline isrequired. 10 or more years experience in healthcare with Medicarerisk adjustment, reconciliation, and reporting experience preferred.A minimum of 2 years supervisory experience is required.

DIRECTOR, COMPLIANCE

This position is responsible for developing, implementing, and pro-viding oversight of all compliance activities related to the Alliancesadherence to laws, regulations, and contracts that govern its business.The position will assess areas of risk, develop the annual audit planand internal audit tools, conduct internal audits, and implement plansto reduce risk and maintain compliance. The position is also respon-sible for compliance training, and managing the intake, investigation/reporting of fraud, waste and abuse incidents. A Bachelors degree isrequired and a minimum of 5 years compliance experience in a man-aged care plan or a community clinic is required. A Masters degreeand certification in Healthcare Compliance (CHC) is preferred.

MANAGER, MEDICARE COMPLIANCE

This position will implement a compliance assessment, audit-ing and monitoring program for the health plans MedicareAdvantage Plan. Responsibilities include coordinating externalaudits and conducting internal compliance audits to ensurecompliance with contractual and regulatory requirements. Otherresponsibilities include creating reports, educating and follow-ing up with business areas to ensure that processes exist todemonstrate compliance.The position will also support the entireorganization with compliance related training. The positioninvestigates, summarizes findings, and reports suspected fraud,abuse, and non-compliance to the Compliance Officer, regula-tory agencies, Medicare Director, and others. A Bachelors degreein a related field is required, a Masters degree is preferred.Knowledge of managed care contractual and regulatory require-ments for Medicare and Medicaid is required.

Alameda Alliance for Health is a public, not-for-profit managedcare health plan for lower income people in Alameda County.TheAlliance provides healthcare coverage to over 130,000 childrenand adults through four programs: Medi-Cal, Healthy Families,Alliance Group Care, and Alliance CompleteCare.

We offer an excellent compensation & benefits package. Please visit our website at www.alamedaalliance.organd click on the Careers button for more specific job information and to apply for these positions. EEO.

Health care you can count on. Service you can trust.

SEEKING A NEW POSITION?

CAN HELP.

We publish advertisements for those seeking

new careeropportunities for just $1.25 a word.

If you prefer discretion, well handle allresponses to your ad.

Call (877) 248-2360, ext. 2, or [email protected].


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MARKETPLACE/EMPLOYMENTPayers & Providers Page 8

PROJECT MANAGER-HEDIS

(Long Beach, CA)

JOB SUMMARY: Position supports the QualityInitiatives Team and Healthcare Informatics in activi-ties related to quality improvement, measurement,reporting and analysis.

ESSENTIAL JOB RESULTS: Manage all aspects ofthe HEDIS project, including, but not limited to, datacollection, abstraction, and the compliance audit. Hire,train and supervise temporary HEDIS staff. Identifydata sources and ensure accuracy and completenessof the HEDIS data repository. Collaborate with otherdepartments on project implementation. Provideweekly status update to management.

Conduct analyses to identify barriers, gaps, and oppor-tunities for improvement. Educate network provid-ers on evidence based clinical guidelines and bestpractices to improve quality of care and service formembers through webinars, on-site meetings, mail andelectronic correspondence. Conduct targeted memberand provider outreach and education via electronicdata exchange, phone calls/IVR, mailings, etc. UtilizeHEDIS/HOS/CAHPS metrics to monitor and improve

clinical outcomes. Maintain professional and technicalknowledge by attending educational and technologicalworkshops.

QUALIFICATIONS: Bachelors or Masters degree inhealth care or related area with emphasis in quantita-tive data analysis. Experience in quality improvementand HEDIS project management. Moderate to strongknowledge in processing of claims, encounters, andpharmacy data. Proficient in SAS/SQL programming.Proficient in Microsoft Office applications. Strong ver-bal and written communication skills with the ability toexpress ideas in a clear and organized manner. Strongorganizational and time management skills to efficiently

handle multiple projects with changing priorities.

FT position, M-F 8 AM to 5PM, with extended work-ing hours and occasional travel as needed. Apply towww.scanhealthplan.com Job Opportunities Req.# 11-415

DIRECTOR,

QUALITY

IMPROVEMENT

JOB SUMMARY: The Director, Quality Improvement is respon-sible for coordinating assigned regulatory, accreditation, clinicalquality and/or service improvement programs. Functions asa leader for assigned health services initiatives handling mul-tiple large-scale complex initiatives. May collaborate on national,regional and multi-plan initiatives. Develops programs in compli-ance with accreditation and regulatory requirements/standardsand monitors ongoing program performance to maintain com-pliance. Acts as a resource for training, policy and regulatory/accreditation interpretation.

DUTIES AND RESPONSIBILITIES: Leads and manages mul-tiple complex initiatives that impact the quality or effectivenessof health care delivery and/or health care services provided to

members, ensuring compliance with accreditation and regulatoryrequirements. Provides an assessment of programs, initiativesand interventions to determine the effectiveness of activities andmakes recommendations to improve outcomes. Develops targetedactivities to improve HEDIS, CAHPS, provider satisfaction andother identified performance measures. Completes project-relatedcommunication, including member/physician mailings, businessplans, graphics, minutes and agendas. Monitors and analyzesoutcomes to ensure goals, objectives, outcomes, accreditation andregulatory requirements are met. Identifies areas of improvementwithin the company and works collaboratively with other depart-ments to develop clinical and non-clinical performance improve-ment projects. Researches best practices, national and regionalbenchmarks, and industry standards. Ensures that clinical andservice quality improvement standards are compliant with accredi-tation, state and federal requirements. Interfaces with contracted

providers or provider groups to promote participation in qual-ity improvement collaborative to improve clinical care outcomes,health care service utilization and costs. In conjunction withmedical director, communicates quality improvement initiatives,results, and/or performance data to participating physician groups.Assess current industry trends and regulations for enterprise-wideadoption to assure quality and effectiveness of health care deliveryand/or healthcare services provided to members. Supports thefunction of the Quality Improvement Committee.

QUALIFICATIONS: Bachelors Degree with Registered NurseLicense or Masters Degree in a related health field (i.e. MPHor MPA) or field of experience. Minimum 2 years experience inclinical/health care environment with related degree program.5 years managed care experience. Experience in compliance,accreditation, service or and quality improvement. Complex proj-ect management experience. Experience with Medicare and/orNCQA preferred.

Competitive salary, plus excellent benefits.If you meet the requirements of this job opportunity,

please send your resume to [email protected] THIRD PARTY AGENCY OR SEARCH FIRMS.

Payers & Providers California Edition – Issue of December 1, 2011

Documents

Transcript of Payers & Providers California Edition – Issue of December 1, 2011