Kaiser Permanente
Quality Assurance Manager - Claims
Downey, CA
• The primary purpose of this position is to manage and coordinate quality management functions and associated operations functions.
• Support the departmental and compliance initiatives to include management of staff, critical department deliverables in support of activities for quality improvement, policy guideline documentation development oversight.
• The position requires research, analysis and project management including timelines and deliverable coordination.
• Supports new product and quality improvement initiatives as assigned.
• Supports internal mock audit functions and provides analysis and corrective action recommendations for claims operations improvement opportunities.
• Assist claims administration with compliance areas relating to Federal, State and organizational rules and regulations, including such things as developing and monitoring to address identified deficiencies and providing consulting services to the operations team to ensure timely execution of established compliance metrics.
• Assists in the development and administration of appropriate policies and procedures relating to regulatory requirements and quality assurance metrics to ensure clear communication of all guidelines
Essential Functions:
• Responsible for supervising Quality Auditors, Sr. Auditor and Supervisor.
• Provides supervision and monitoring of Quality Auditors to ensure accuracy and consistency in auditing of claims.
• Serves as an expert resource in the areas of documentation, CMS, DMHC, Medi-Cal and DHS regulations and compliance issues surrounding regulatory requirements associated with external and referral claims.
• Maintains and monitors the internal process for auditing, monitoring and identify training for auditing staff.
• Conduct analysis and reporting of quality and compliance audit findings to Compliance Manager, Claims Manager, Director, and outside departments.
• Assists in the development and administration of appropriate policies and procedures relating to regulatory requirements and quality assurance metrics to ensure clear communication of all guidelines.
• Oversees staff that conducts focused audits, analyze results and provide recommendations to issues identified.
• Manages development and implementation of processes that will effectively monitor/track compliance requirements, including reports, performance metrics and scorecards.
• Upon completion of an end to end process review, make appropriate recommendations to address and resolve issues identified so as to eliminate compliance and quality risks. Follow-through on recommendations to ensure implementation.
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