Mgr, Quality Assurance - HPRA - Lenexa, KS

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POST DATE 8/17/2016
END DATE 10/10/2016

Quest Diagnostics Lenexa, KS

Lenexa, KS
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


The Journey Begins with you.

There's quite a distance between wondering and knowing. And for patients waiting for answers to important health questions, it's a road they want to travel as quickly as possible.

At Quest Diagnostics Incorporated, we understand urgency. But more than speed, we focus our energies on accuracy. Currently, we seek a Mgr, Quality Assurance - HPRA - Lenexa, KS.

Schedule: Monday - Friday, 8am - 5pm, Day Shift

*Salary dependent upon experience

REQ # 3762954



Responsible for leading and managing clinical operations for the Health Plan Risk Assessment (HPRA) department of ExamOne, while ensuring compliance with state and federal regulations and guidelines, CMS compliance and audit guidelines, and HIPAA, NCQA and HEDIS standards. The scope of these operations comprise 1) onsite member health assessment, screening, health education, and lab draws and testing services, 2) ensuring clinically accurate, comprehensive and specific CMS/RAC-compliant documentation of health and clinical indicators and diagnoses supporting HCC coding and care planning, 3) ensuring the clinical efficacy of the collection and reporting of assessment, screening, and test results assessment results and related data, 4) managing the credentialing process, training, and management of advanced nurse practitioners of HPRA services, and 5) oversight and facilitation of the HPRA Quality Assurance program in support of the clinically efficacious, effective and compliant delivery of HPRA services.




1. Lead, manage and direct HPRA clinical operations under the direction of the Operations Director, with dotted line reporting to the HPRA Medical Director. Influence may be exerted both directly and indirectly through the management of interdisciplinary teams, contractors and vendors.

2. Lead the credentialing, training, and ongoing activities of providers in the administration of onsite member health screening and risk assessment.

3. Represent HPRA s clinical operations, network management and QA program to clients, prospects, providers, suppliers, vendors, to accrediting, credentialing and auditing entities, and to divisions of ExamOne/Quest Diagnostics.


2. Ensure HPRA clinical operations, practices, policies and procedures are in compliance with CMS, DHHS, HIPAA, NCQA, JCAHO, CLIA and related state and federal regulations, audit guidelines and industry standards.

3. Monitor published guidelines for revisions to regulations and/or accreditation standards to prepare for and ensure compliance in HPRA clinical operations.

4. Ensure all providers and suppliers have appropriate licensure and accreditation and that personnel have appropriate qualifications, certification and/or licensure as deemed by federal, state, and local regulations.

Provider Credentialing, Training, Proficiency and Quality

5. Develop and oversee provider training program, and ongoing proficiency monitoring and corrective action, to ensure safe, compliant, effective and efficient administration of HPRA assessment, screening, lab collection, testing, diagnosis and clinical documentation by employees and providers.

6. Ensure that all HPRA employees and providers are aware of applicable regulatory requirement, industry standards and company standard operating procedures regarding CMS, DHHS, HIPAA, NCQA, HEDIS, JCAHO and CLIA as appropriate to the employees job duties and responsibilities.

Quality Assurance/Quality Improvement

7. Establish policies and procedures and internal infrastructure necessary to ensure the ongoing review of quality indicators relative to HPRA operations. Oversee the development of corrective action plans where needed., and reporting mechanisms necessary to ensure transparency into the HPRA QA process for purposes of internal and external audits and client due diligence.

8. Facilitate the tracking, documentation, reporting and action plans relative to the HPRA Quality Assurance (QA) activities for approval by the HPRA Director of Operations.

9. Develop and monitor Quality Assurance indicators, issues, corrective actions and outcomes, for inclusion in the division-wide QA program. These include but are not limited to: Reportable Quality Issues and action plans, operational and provider proficiency, revised reports tracking, and performance on audits and inspections.

10. Ensure that any and all suppliers and delegated services maintain a comprehensive Quality Assurance program meeting HPRA, Quest, CMS, DHHS, HIPAA, NCQA, HEDIS, ACA, CLIA and other similar requirements and standards.

11. Conduct monthly QA meetings with required participation by all areas responsible for and impacting the delivery of HPRA services.

12. Prepare, revise and distribute to employees and providers a QA Manual that includes applicable HPRA, Division and Company policies and procedures. Ensure all employees are trained on the policies as appropriate to their job duties and responsibilities. Ensure all QA policies have annual review as per the QA Committee policies and procedures.




* Bachelors of Science in Nursing

* Masters of Science in Nursing (preferred)

* Masters of Science in Health Administration (preferred)



* Certified Registered Nurse, Certified Nurse Practitioner.

* Clinical Nurse Specialist, or Clinical Nurse Leader - preferred

* AAPC Certified Professional Medical Auditor, Certified Professional Coder - preferred


Work Experience:

1. 5 years minimum experience leading complex medical managing functions for managed care organizations, provider groups, health services organizations and/or healthcare delivery systems - to include health risk assessment, mobile laboratory, in-home care, or outpatient services.

2. Three years overseeing quality management and/or credentialing programs for managed care organizations, provider groups, healthcare services, or delivery systems

3 Experience supporting internal interdisciplinary teams including product development, sales and marketing, client implementation, account management, and compliance within large and complex organizations.

4. Strong working knowledge of and experience developing clinical processes in compliance with CMS RAC and Compliance Requirements and Guidelines, HIPAA, DHHS, state and federal regulations, and managed Medicare/Medicaid industry best practices

5. Experience leading successful NCQA, CLIA, or JCAHO accreditation initiatives.

6. Five years experience directly managing teams and/or networks of nurses, physicians, healthcare providers, medical technicians and/or parameds.

7. HEDIS improvement experience.



Demonstrated ability to influence and create