Qualifications

High level of knowledge related to Home Care, Home Health, Case Management, UDS, and HEDIS standards, California Department of Public Health, and the Centers for Medicare and Medicaid Services standards and regulations
Professional must have four or more years of recent performance improvement, quality management, and risk management experience in an acute care setting
Excellent English written/verbal communication skills
Computer-skilled with experience using Microsoft Office software at an intermediate level
Intermediate to advanced-level Microsoft Excel database and statistical analysis skills required
Ability to negotiate the physical environment safely
Ability to completely lift up to 35 pounds
Ability to lift patients (with assistance from co-workers and/or lifting devices)
Ability to translate and understand written communications
Ability to negotiate the physical environment safely
Ability to understand and translate auditory communications accurately

Responsibilities

Under the direction of the Clinical Director, Clinical Oversight Senior Manager, and Operations Director, the Performance Improvement and Risk Management Manager is responsible for administrative, technical, and coordinating support to and for working collaboratively with the Performance Improvement Council (PIC) in the development, implementation and evaluation of the Performance Improvement Program that meets accreditation and regulatory guidelines.
He/She manages and coordinates the Performance Improvement and Risk Management Programs throughout the organization.
In collaboration with the Clinical Director, Business Manager, and Director of Operations, develops and maintains a performance measurement work plan and reporting calendar to ensure timely data collection, aggregation, analysis, and reporting of established health plans reports, and performance measures related to key operational and clinical processes and outcomes.
Oversees the preparation and timely submission of mandatory reports to the appropriate regulatory agencies.
Works with the billing department to improve claims
Supervises and monitors the staff in the office
Oversees and monitors Teramind activities
Leads improvement teams through the Plan-Do-Study-Act cycle and reports on outcomes.
Develops and implements quality improvement programs, which include identifying areas for improvement, setting goals, and designing and implementing strategies to address them.
Tracks the effectiveness of implemented changes and makes adjustments as needed.
Leads quality improvement team and collaborates with cross-functional teams to achieve quality improvement goals.
Responsible for the workflow processes.
Communicates quality improvement initiatives and results to stakeholders, including staff, leadership, and patients.
Develops and Implements Quality Metrics: This includes establishing key performance indicators (KPIs) to measure and track quality improvement efforts.
Identifies the root causes of problems and develops effective solutions to address them.
Manages electronic storage of quality improvement reports to promote ongoing access for key stakeholders.
Ensures Compliance: This includes staying up-to-date with relevant regulations and standards and ensuring compliance.
Manages BleHealth Compliance program. Develops and maintains a written BleHealth compliance plan and annual evaluation of the plan’s effectiveness; ensures that all required elements of a compliance program are addressed.
Focuses on Patient Safety and Outcomes: Prioritizes patient safety and works to improve patient outcomes.
Develops and maintains policies and procedures.
Oversees BleHealth's wide risk management program, develops and maintains a written BleHealth risk management plan, and annually evaluates the plan’s effectiveness.
Develops and manages processes for internal incident reporting, investigates and evaluates claims and potential claims.
Manages BleHealth's comprehensive patient safety program, developing and maintaining a written patient safety plan and conducting annual evaluations of the plan’s effectiveness. Additionally, develops and maintains policies and procedures related to the patient safety program.
Collaborates with executive staff in the investigation of clinical events, including sentinel events, near misses, and significant adverse events; leads and/or participates in the development of root cause analyses as directed by the CMO, clinical director, and operations director.
Promotes a Culture of Quality: Fosters a culture of continuous improvement within the organization.
Conducts Audits: Performs internal audits to ensure compliance with quality standards.
Contacts members and Close members’ care gaps
Organizes, compiles, and interprets data, HEDIS, and non-HEDIS data for trending and reporting.
Coordinates monthly and annual dissemination of reminder letters and contacts related to area(s) of specialty.
Works with Management to identify strategies and opportunities for improving the health status of BleHealth’s membership.
Participates in the development of health management system programs, clinical practice guidelines, and preventive health initiatives. Works with network providers to implement identified improvement processes.
Takes responsibility for assigned areas of standards to ensure that accurate policies and procedures are in place, and BleHealth’s progress is documented.
Attends meetings with internal workgroups and external business parties.
Prepares reports and presentations for internal and external audiences.
Actively participates in the development, implementation, and oversight of assigned internal policy and procedures.
Responsible for adhering to the principles of continuous quality improvement to ensure that BleHealth’s members receive the highest quality of service and care.
Assists with the coordination of health care guidelines as they apply to the area(s) of focus. Edits guidelines yearly to develop a member version.
Productions of health education materials on issues related to specialty area(s) and coordinate the distribution of these materials to members.
Continuously works to keep information up-to-date as related to specialty area(s). Work with the Marketing Department to update the website with new and expanded information as needed.
Coordinates, consults with, and works with clients, as needed, to assess, design, implement, and evaluate health promotion programs at their worksite, and other consulting programs.
Responsible for coordinating and maintaining the BleHealth disease management program
Collaborates with the Marketing Department to facilitate staff and member communications.
Answers member questions regarding programs, preventive health care initiatives, wellness initiatives, disease management initiatives, and other health-related concerns as necessary.
Responsible for adhering to the practices and principles of confidentiality outlined in BleHealth’s HIPAA Privacy Policies & Procedures.
Adheres to and upholds the BleHealth Mission, Vision, Values, and BleHealth Health Service and Performance Standards.
Provides care management services
Engages members
Performs coordination of care, and transition of care.
Connects members with resources.
Performs other duties as requested.
In collaboration with the Medical Staff, Patient Care Services, Nursing, Support Services and other departments, the Performance Improvement and Risk Management Manager implements performance improvement (PI) and risk management programs through department-specific and organization-wide planning, coordinates reports to the Executive Team, and accreditation/regulatory agencies
Facilitates the training of BLEHEALTH staff in the use of performance improvement tools, performance initiatives, chart’s documentation, onboarding, corrective action plans development and implementation
Maintains current knowledge of Home Health, Home Care, CalAim, accreditation standards, California Department of Health (CDPH), and Centers for Medicare and Medicaid (CMS) regulations
In addition, the Performance Improvement and Risk Management Manager is responsible for coordinating audit activities.
This position requires providing administrative standards compliance supervision to departments, which provide care/service to members in a manner that demonstrates an understanding of the functional, and/or developmental age of the individual served
This position requires the full understanding and active participation in fulfilling the mission of BLEHEALTH.
It is expected that the Performance Improvement and Risk Management Manager demonstrate behavior consistent with BLEHEALTH values and shall support its strategic plan, goals, and direction of the Performance Improvement and Risk Management Plans
Greets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area
Asks how the customer may be helped with interest and concern
Listens attentively, does not interrupt
Accepts ownership and takes action to resolve customer needs and/or concerns
Is attentive and responsive to the expectations of clinical staff, co-workers and direct reports
Accepts constructive criticism and modifies actions accordingly
Is generous in acknowledging a job well done
Uses words and behaviors that express consideration, concern and respect
Facilitates and holds staff accountable for meeting department customer service standards in the performance of duties
Utilizes telephone skills effectively
Keeps all private information about staff or patients confidential
Identifies customers and their service requirements
Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc

VALUE ADDED – INCREASES WORTH OF SERVICE TO BLEHEALTH

Participates in marketing activities of BLEHEALTH as requested, including but not limited to committees/task forces, speaking engagements, conducting tours, BLEHEALTH sponsored events.
Contributes to marketing materials such as brochures, newsletters, teaching materials
Participates in staff recognition activities in ways that reward behaviors reflecting positively on BLEHEALTH.
Engages in interdepartmental /multi-department/house-wide process improvement forums/task forces/committees
Offers and implements solutions to challenges/problems
Assist with development-related activities including fund raising programs & activities
Monitors the marketplace and recommends new and creative business opportunities
Analyzes targeted existing services and product lines for cost/benefit and develops appropriate strategies to improve growth where applicable
Attends/participates in activities that contribute to professional growth and development

PERFORMANCE IMPROVEMENT and RISK MANAGEMENT ACTIVITIES

Responsible for coordinating, facilitating and monitoring BLEHEALTH-wide PI activities/initiatives, including Core Measure data abstraction, analysis, and committee reporting
Responsible for coordinating, facilitating, and monitoring patient satisfaction improvement initiatives, including data reporting to BLEHEALTH committees
Responsible for coordinating, facilitating, and monitoring BLEHEALTH-wide risk management activities/initiatives including data abstraction, analysis, and reporting
Responsible for coordinating and facilitating hospital-wide accreditation and regulatory agency survey preparedness and readiness, which includes staff and physician education

PERFORMANCE IMPROVEMENT and RISK MANAGEMENT ACTIVITIES (cont.)

Responsible for conducting a minimum of two failure mode and effects analyses annually and reporting findings to appropriate senior management and PI committees
Responsible for conducting and/or facilitating a minimum of four Root Cause Analysis (RCA) annually and reporting findings to appropriate senior management and PI committees
Responsible for coordinating and facilitating peer review activities as needed
Ensures policy and procedure standards comply with local, state, and federal law and regulatory requirements
Maintains effective communication within the department, division, and with all relevant colleagues, divisions, and Medical Staff
Coordinates/facilitates PI and risk management activities through appropriate committee assignments, defined feedback mechanisms, and periodic evaluation
Provides a climate for PI and risk management goal achievement by educating and encouraging excellence in practice
Recommends changes in the administrative policies that conform to accreditation standards and California/Federal regulations
Develops and implements department-specific policies and procedures
Responsive and flexible when interacting with other managers/directors
Submits accurate and timely status reports to senior management and/or hospital committees
Provides continuous quality improvement consultative services to all departments, including leadership, medical staff, nursing, and other ancillary departments, to ensure the development and implementation of a quality management process
Orients/provides employee training related to performance improvement and outreach
Ensures that mechanisms are in place for ongoing PI and risk management data collection, analysis, and reporting for important processes and outcomes throughout the organization to maintain and improve the quality of patient care and services
Identifies and reports national/regional benchmarks or outcomes, excellence targets that assist in identifying/supporting performance improvement opportunities
Identifies trends and displays opportunities for BLEHEALTH, medical, department/unit care, and/or service improvement via aggregation of data, information, and indicators
Uses a disciplined process improvement method (the FOCUS-PDCA methodology- identifies the process, barriers to outcomes and corrective action plans) and performance improvement tools
Oversees the systematic monitoring and evaluation of patient care and services, as it relates to regulatory and accreditation compliance, and performance improvement activities

PERFORMANCE IMPROVEMENT and RISK MANAGEMENT ACTIVITIES (cont)

Assures that process improvement teams and committees develop strategies (based on their monitoring activities) to improve patient care outcomes by assuring that BLEHEALTH practices reflect the best known science; that best practices are identified and emulated; that variations in clinical care processes are reduced; that reversible causes of patient care complications are identified and reduced or eliminated and that patient outcomes are both measured and continuously improved, including but not limited to Core Measure indicators, FEMA, patient safety initiatives, clinical pathways, restraint management, staffing effectiveness, Health plans, CDPH corrective actions plans.
Responds to Health Plans, CDPH Statement of Deficiencies, and Plan of Corrections within the designated time frame (due date)
Responds to grievances and complaints within the designated time frame
Collects, trends, reports, and displays baseline and concurrent outcomes data demonstrating the effectiveness of action plans as compared to national/regional benchmarks or outcomes excellence targets
Recommends modification(s) to corrective action plans as appropriate
Ensures that activities are implemented to resolve defined problems
Coordinates, manages, and keeps accurate records/files for a large volume of information that includes data collection, aggregation, and display of information, statistics, the dissemination of information to appropriate committees and personnel, reports, corrective action plan, status/resolution; and follow-up activities
Utilizes opportunities to function as both a designer and initiator of controlled change as needed or appropriate to restructure BLEHEALTH clinical monitoring activities to reflect the vision and mission of BLEHEALTH as well as current/anticipated trends
Remains current concerning industry-wide Diagnostic-Related Group-specific best practices and evaluates such best practices for implementation
Supports and empowers employees to improve the quality of care and/or service
Possesses and maintains a working knowledge of Health Plan standards, State of California laws and statutes (e.g., Title XXII), CMS regulations, Home Health, Home Care, policies and procedures, and community standards
Evaluates, monitors, and sustains compliance with accreditation and regulatory bodies
Coordinates the continuous readiness for the Joint Commission, Health Plans, CDPH, and CMS surveys in collaboration with the Performance Improvement and Operations Committees
Facilitates/assists with the annual evaluation of the seven Environment of Care safety plans and revision of the plans
Performs other duties as related or assigned
Ensures unusual occurrence forms are completed within 24 hours of the event
Completes investigations/assessments thoroughly and in a timely; corrective action plans are formulated and implemented
Promptly reports any suspected or potential violations of laws, regulations, procedures, policies, and practices, and cooperates with investigations
Conducts all transactions in compliance with all corporate and medical center policies, procedures, standards, and practices
Facilitates/fosters compliance with all applicable laws, regulations, procedures, policies, and practices required by the job, based on the scope of practice of the position
Facilitates identification and reporting of occurrences of potential liability to the Hospital
Uses information sources appropriately in department/unit operations
Uses department-specific information systems applications efficiently and effectively
Accesses and creates department-specific information system application reports
Conducts reality and validation assessments of data processed by the department
Serves as an effective resource to departments to ensure accurate entry/updating of department-specific systems applications
Complies with BLEHEALTH policies, accreditation agency standards and state and federal confidentiality requirements related to management of information, including HIPAA
Obtains necessary training prior to initial equipment and software use
Uses software at an intermediate to advanced level

Skills and Qualifications:

Strong analytical and problem-solving skills.
Excellent communication and interpersonal skills.
Leadership and team management skills.
Knowledge of quality improvement methodologies (e.g., Lean, Six Sigma).
Experience in data analysis and reporting.
Understanding of relevant regulations and standards.
Ability to work independently and as part of a team.
Experience in healthcare settings (depending on the specific role).

Job Qualifications and Skills:

Preferred Master’s degree in public health, Healthcare Administration, or Bachelor’s degree and 2-3 years of experience working in the healthcare field.
Demonstrated leadership skills, including excellent oral and written communication skills.
Strong knowledge of healthcare clinical fundamentals, patient safety standards, performance improvement standards, and leading quality improvement teams.
Computer skills and knowledge of applicable software programs.
Ability to work with diverse populations
Ability to travel and flexibility with schedule

PERFORMANCE IMPROVEMENT AND RISK MANAGER

About the Job

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