Lumeris Manager, Grievances and Quality Improvement in St. Louis, Missouri
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Manager, Grievances and Quality Improvement
The Quality Improvement Manager position is accountable for the planning, coordination and implementation of quality management and improvement initiatives for the Essence healthcare plan as well as the daily operations of the Quality Management Department. The position will ensure that the organization meets its regulatory and contractual requirements and accreditation standards by developing, implementing, measuring and reporting on activities designed to improve the quality of care and service delivered by departments and its contractors, including the contracted provider networks, and is in compliance with all applicable federal and state regulations. The Quality Improvement Manager also acts as a consultant to other departments engaged in quality improvement activities to ensure programs and services are implemented at the highest standards and members receive the highest level of care.
Role and Responsibilities
Reviews regulatory and contractual requirements and accreditation standards related to quality management to ensure compliance between standards and internal operations.
Develops, implements and maintains systems, policies, and procedures for the identification, collection, and analysis of performance measurement data.
Develops strategic plan to foster organizational compliance with relevant current standards and requirements as well as assisting in the preparation for future activities to lay the groundwork to meet requirements necessary for NCQA and other accreditation.
Works in conjunction with Director and Chief Medical Officer to develop, implement and maintain a Quality Management Program (QMP) plan with sufficient written policies and procedures to support the achievement of regulatory and payer contractual requirements and accreditation standards.
Conducts review/audits of quality metrics for reporting to quality committees, and prepares progress summaries and other reports as needed to support continuous quality improvement.
Represents quality improvement function in all internal quality committees, as well as during external regulatory, accreditation and other business functions.
Performs, or ensures staff perform program development, improvement and individual data management activities (e.g. CCIP/QIP, medical record review, member outreach efforts, etc.)
Leads and Manages the daily operation of the Quality Management department, including staff hiring, orientation, supervision, monitoring of expenses, preparation of budgets, reporting of activities, achievement of objectives, determination and facilitation of quality of care/service grievances, etc.
Monitors and tracks adverse events (i.e. Sentinel events, PCP changes, etc.) including documentation.
Identifies and refers clinical cases to peer review
Facilitates/participates in quality related meetings and programs
Performs other duties as assigned
Experience, Qualifications, and Education
BSN, LPN, RHIA preferred
5+ years of experience in Quality Management and experience in Medicare Care Management
3+ years demonstrated leadership and team development skills
3+ years experience and proven success managing, implementing and auditing clinical quality programs
Proficiency with clinical data management and statistical quality tools
Proficiency with MS Office applications
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
Excellent verbal and written communication skills.
Lumeris is an EEO/AA employer M/F/V/D.
St. Louis, MO
XL - FT
Join Our Growing Team!
Lumeris serves as a long-term operating partner for organizations that are committed to the transition from volume- to value-based care and delivering extraordinary clinical and financial outcomes. Lumeris enables clients to profitably achieve greater results through proven playbooks based on collaboration, transparent data and innovative engagement methodologies. Lumeris offers comprehensive services for managing all types of populations, including launching new Medicare Advantage Health Plans, Commercial and Government Health Plan Optimization, and Multi-Payer, Multi-Population Health Services Organizations (PHSOs). Currently, Lumeris is engaged with health systems, provider alliances and payers representing tens of millions of lives moving to value-based care.
Over the past seven years, we have tripled in size to more than 800 employees and built the only solution on the market with our proven outcomes. For the past six years, Essence Healthcare, a long-standing Lumeris client, has received 4.5 Stars or higher from the Centers for Medicare and Medicaid Services (CMS). Essence Healthcare was Lumeris’ pioneer client and has been leveraging Lumeris for more than a decade to operate its Medicare Advantage plans, which serve more than 60,000 Medicare beneficiaries in various counties throughout Missouri and southern Illinois.
In 2018, Lumeris was named Best in KLAS for Value-Based Care Managed Services in the area of client-reported impact on the Triple Aim by KLAS Research. This was the third year in a row Lumeris received the award, and it has only been given for three years. As the industry’s most reliable and effective partner for developing population health management solutions, our success is driving tremendous growth in our company. Join us today in making a real difference in how healthcare is delivered!
Why Join Lumeris?
At Lumeris, you will be part of team that is focused on solving the nation’s healthcare problem, and you will be able to contribute to our purpose. Our environment is fast-paced, change-oriented and focused on growth and employee engagement. At Lumeris, we know that talent is best utilized when given the opportunity to succeed. That is why we have removed the boundaries that inhibit success and focus on fostering an environment that allows employees to utilize their talents.