Quality of Care Manager (RN) – Medicare Advantage

Local Jobs Cigna
  • United States, Hartford, CT 06152 View on Map
  • Post Date: June 18, 2020
  • Apply Before : July 18, 2020
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Job Description

This is a work from home position, anywhere in the US. Manager, Quality of Care

Under the direction of the Director of Quality Compliance, the Quality of Care (QOC) Manager (Quality Clinical Management Manager, Band 4) conducts oversight and management of activities related to Cigna Medicare’s Quality program. The QOC Manager directs the development, implementation, and ongoing effectiveness of quality of care investigation process and provides leadership and consultation in identifying and implementing strategic and tactical solutions to actual or potential adverse events.

The QOC Manager is responsible for supervising the QOC team consisting of administrative and nursing staff and is accountable for creating a culture of compliance, ethics and integrity. The QOC Manager is responsible for ensuring ongoing compliance for areas of assigned responsibility and has advanced knowledge of health care delivery systems and state and federal regulatory requirements, including, but not limited to, Centers for Medicare and Medicaid Services (CMS), State and National Committee for Quality Assurance (NCQA).

Major Duties and Responsibilities:
Oversees the investigation process of quality of care grievances and potential quality of care issues that include, but are not limited to, adverse events, critical incidents and never events.

Works in collaboration with CMO, VP of Clinical Quality, Director of Quality Compliance, Market Medical Executives, and business matrix partners in the identification, clarification, improvement opportunities and investigation of quality of care issues. Works closely with Grievance Administration (GAD) to identify/clarify QOC issues and maintain turnaround times

Participates and support in the quality of care case reviews, and reports to appropriate committee for review and severity level determination via the peer review process.

Establishes and maintains tracking and monitoring systems for quality of care activities according to regulatory requirements, policies and procedures, and State contractual agreements, as applicable.

Monitors performance against established targets, including conducting and evaluating team’s inter-rater reliability testing.

Maintains knowledge of policies and procedures and assures team performs assigned duties in accordance with applicable regulatory requirements, State and accreditation standards.

Ensures high risk, high volume, and unusual events are monitored concurrently and retrospectively as they occur.

Coordinates the regular and systematic review of all potential quality of care issues in accordance with federal, accreditation, and state requirements.

Plans and conducts strategies to effectively develop individuals and build teams to ensure a competent and motivated staff.

Supervises assigned staff to include interviewing, selecting, training, coaching, motivating, evaluating, counseling, disciplining, and terminating in compliance with equal employer opportunity (EEO) goals and personnel policies of the organization.

Establishes an orientation program for new staff members. Provides team orientation and leverages other appropriate staff to provide aspects of orientation to new staff.

Monitors productivity of department staff and establishes productivity minimum expectations for each role. Provides regular feedback and support to staff in meeting performance expectations.

Performs other job-related duties as required;

Core Competencies and Skill Requirements:
Strong knowledge of common patient disease processes and usual methods of treating them;

Thorough knowledge of medical terminology and commonly used equipment;

Ability to effectively evaluate medical records for appropriateness of care;

Ability to assess and judge the clinical performance of physicians and other health professionals;

Strong analytical, assessment and problem-solving skills;

Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside the organization;

Facilitates an atmosphere of collaboration and team work;

Ability to effectively manage both clinical and non-clinical staff in support of both individual staff and team success;

Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;

Intermediate skills in Word, PowerPoint, Excel, and Outlook with basic ability to enter data into and navigate through a database;

Maintains confidentiality of all sensitive documents, records, discussions and other information generated in connection with quality of care activities;

Self-directed and able to work independently. Uses appropriate judgment to seek assistance and ask questions ;

Keeps Director of Quality Compliance updated on overall activities, issues identified, and actions to address issues;

Operates with target dates and deadlines and is able to meet deadlines with successful outcomes.

Appropriately negotiates changes to target dates and holds staff accountable similarly to target dates;

Strong attention to detail and work accuracy;

Required Education, Experience, and Training:
Registered nurse with an active and unrestricted license;

Five (5) years of experience in the direct patient care setting;

At least one (1) year of experience in health care Quality Improvement;

Two (2) years of management experience;

Working knowledge of state, federal regulatory, State and accreditation requirements, particularly related to quality of care activities;

Willing to travel at least 25%

Preferred Requirements:
Bachelor’s Degree in Nursing, Health Administration or other healthcare field preferred;

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require an accommodation based on your physical or mental disability please email: [email protected] Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.


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