KFMC - Contract Manager, Quality Review

KFMC 2021Position:  Contract Manager, Quality Review
Job Classification:
Exempt, Full-time
Work Schedule: Mutually Determined
Reports to: Vice President of Quality Improvement and Review
Location: Oklahoma City, OK 
SUMMARY OF DUTIES: The individual holding this position will provide overall direction for the Medicaid External Quality Review Organization (EQRO) Customer Team and Case Review Teams, based on the organization’s strategic directions and contract requirements. He/she will rely on his/her familiarity with the current national, state and local health care delivery systems developed from hands-on relevant experience and subsequent administrative work with providers, insurers and policy makers.  He/she will coordinate the day-to-day activities of the EQRO team and play a major role in the execution of external quality review activities, particularly coordinating work process development that fosters the quality improvement contract with State Agencies.  This individual is responsible for planning, implementing, monitoring, and evaluating all activities as described in executed contracts with various states.  This Contract Manager works collaboratively with the Case Review Manager to oversee and ensure the effectiveness of the Case Review Team.  He/she may also coordinate/oversee other various smaller grants and contracts.  The ability to communicate effectively both orally and in writing will be required.

TEAM FUNCTION:  The primary mission of the EQRO Team is to facilitate and help ensure quality care within awarded State Medicaid Managed Care and Children’s Health Insurance Program (CHIP) populations.  This is achieved through compliance review, technical assistance and validation of performance improvement projects, measurement and validation of certain indicators (such as HEDIS), provider network validation, validation of provider and customer satisfaction surveys, studies, and other external quality review activities.
The primary mission of the Case Review Team is to provide Independent Review Organization (external and internal review) services, as well as independent peer review services. Case review activities include consultation in the area of coding quality of care, and recruitment for physician review.
Internal Work

  1. Responsible for planning, implementing, monitoring, and evaluating the external quality review program for Medicaid Managed Care/CHIP which includes the following:
  • Project deliverables/milestones/project plans
    • Works with leaders of each task to assure that deliverables are appropriately developed, meet requirements and professional standards, and are conducted according to specifications
  • Contract deliverables
    • Keeps teams updated on changes in contract requirements i.e., changes to contract requirement or other communications from contractor
    • Assure all contract deliverables meet or exceed contractual requirements and Federal EQR Protocols.
    • Assures that resources required to conduct project work are available for project teams and facilitates overcoming obstacles impacting project efficiency.
  • Contract/task/subtask work plans
  • Assures that work plans are developed, feasible, initiated, reviewed/revised according to required schedule
  • Assures that work plans meet contractor’s standards/expectations
  • Internal Quality Control (IQC) plan
    • Assures that IQC plan is developed and frequently reviewed/revised to reflect current project team practice
    • Supports changes to team practices that improve the quality of the work performed, based on IQC results

2.    Provides administrative and clinical oversight to the EQR and Utilization Review Teams.

  • Fiscal oversight
    • Evaluates and approves timesheets.
    • Evaluates and approves educational requests for team members within constraints of KFMC policies.
    • Evaluates and approves special purchase requests.
    • Evaluates and approves expense requests.
  • Communication
    • Coordinate periodic meetings of the EQRO Team and assure periodic Case Review Team meetings occur to facilitate information sharing and team cohesiveness.
    • Assure appropriate and accurate communications between KFMC and contractors.
  • Supervise all staff on the EQRO Team and oversee supervision of Case Review Team
    • Conduct and oversee annual performance reviews.
    • Implement Performance Improvement Plan as necessary.
    • Oversee staff development plan, including orientation and on-going education.
  • Manages resources to facilitate accomplishment of EQR and Case Review Team workload.
    • Realigns team members’ workloads to accomplish contract requirements as needed.
    • Assists staff members in the planning, implementation and completion of the work when required.
    • Assumes team responsibilities to facilitate work completion as appropriate (e.g., during times of staff absence, increased workload, etc.).

3.    Assures that the EQRO and Case Review Teams contribute to the overall success of the organization.

  • In conjunction with team members, strategizes, develops, implements and monitors the strategic plan for the EQRO and Case Review teams, providing quarterly updates and modifications as necessary.
  • Provides support for performance improvement activities as needed for any KFMC contract or requested activity.

4. Assist with and participate in leadership activities:

  • Participate in Leadership Group meetings and activities.
  • Represent the organization at regional and national meetings relevant to EQRO and Case Review activity, as appropriate.
  • Represent the organization at state and community meetings.  This position serves as a representative of the organization, maintaining and developing relationships with external contacts and the community at large.

5. Monitor the performance of consultants and subcontractors to ensure compliance with subcontract deliverables.

External Work

  1. Communicates with external partners, organizations, agencies in the accomplishment of project or corporation activities.
    • Assure appropriate and accurate communications among KFMC, State Medicaid agencies, contracting Managed Care Entities (MCEs), and other various stakeholders.
  2. Coordinate customer satisfaction survey development, distribution, analysis, and reporting as determined by Leadership Group.
  3. Contribute to the achievement of organizational and work team goals by demonstrating awareness of KFMC values.
  4. Keep Vice President of Quality Improvement and Review, and the EQRO and Case Review Teams, informed of all activities within area of responsibility.
  5. Promote KFMC continuous quality improvement (CQI) philosophy within the team (i.e. team building, communication, process analysis) as well as between teams.
  6. Contribute to the achievement of the organization’s Mission and Strategic Plan by developing and implementing team goals and activities that are aligned with this Mission and Plan.
  7. Other duties as assigned.

Education and Experience:
Graduate of an accredited college or university with a degree in a relevant field. Preference will be given to candidates with advanced degrees. Minimum of three years of experience in either managed care or performance improvement. Minimum of three years supervisory experience is preferred. Experience in government contracting, quality improvement and review, research, program evaluation, and regulatory compliance preferred. 
Knowledge, Skills and Abilities:

  • Familiarity with the health care delivery system and with health care continuous quality improvement activities, especially managed care organization activities, is required.
  • Familiarity with the External Quality Review Organization structure and activities, the Centers for Medicare and Medicaid Services (CMS) Health Care Quality Improvement Organization (QIO) Activities, and KFMC's review activities is also desired.
  • Ability to effectively communicate with all health-related professionals.  Ability to prepare and present clear, concise reports.
  • Ability to understand and carry out complex directions.
  • Ability to function effectively with minimal supervision.
  • Ability to recognize and deal effectively with both the internal and external customers of the organization.
  • Able to interact and coordinate activities of a variety of disciplines and levels of management.
  • Must be able to travel by automobile or airline as dictated by the responsibilities of the position.

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