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Director of Quality for Clinical/Acute Care

Pivotal Solutions, Inc. Portland ,ME
  • Expired: over a month ago. Applications are no longer accepted.
Job Description

Our client, based in Manhattan, NY, is looking to hire a Director of Quality for Clinical/Acute Care.

I have attached below the job requirements for your review.

If you are not interested in this position, but can refer to me a viable candidate that I place with my client for atleast 90 days, I will pay you a REFERRAL FEE of $3,000.

If you have the required experience and interest, please email me a current resume, along with your responses to the following questions:

*** How much experience in years do you have working in a clinical acute care setting?

*** How much experience in years do you have working in a clinical supervisory, staff management role?

*** Do you have familiarity with using clinical care guidelines?

*** How much experience in years do you have working with utilization management for a health insurance payer or hospital?

*** Do you have experience with either URAC or NCQA accreditation for a UM department?

*** How much experience in years do you have working with chart/claims review in ICD 9 & 10, CPT coding and DRG assignment/validation?

*** How much experience in years do you have teaching healthcare classes addressing patient care, utilization/quality management principals, documentation & regulatory requirements?

*** Do you hold a Master’s degree in Nursing, Health Administration or Education?

*** What is your visa status (US Citizen, Green Card Holder, H1-B, etc…)?

*** What is your desired salary?

*** Why are you looking for a new position?

*** Where do you currently live (city, state)?

*** Are you able to work in NYC, NY?

*** What is your availability to start a new role?


Thank you!


Steven Edelman

Managing Partner

Pivotal Solutions, Inc.





Job Description


Department: Operations


Staff Title: Director of Clinical Quality and Training


Reports to: Senior Medical Director


Working Conditions: Full time (M-F) Hours 9 - 5


Position Summary: directs and coordinates operations for organization wide quality management program, assists in the supervision of UM functions under UM Director and works with all department heads providing feedback and training from quality audit and monitoring tasks.





  • Visual and Auditory comprehension & function for written & verbal communication.
  • Manual Dexterity with ability to use computers and other office equipment necessary to perform assigned tasks
  • Ability to access various settings, negotiate architectural barriers (i.e. stairs) in office
  • Ability to use Public Transportation to commute to work



  • BS required; Master’s degree in Nursing, Health Administration, Education preferred



  • A minimum of four years of clinical experience in an acute care setting including minimum of 2 years of supervisory, staff management experience
  • Minimum five years’ experience in utilization/quality management for a health insurance payer or hospital.
  • At least 1 year of chart/claims review experience in ICD 9 & 10, CPT coding and DRG assignment/validation
  • Three years teaching healthcare classes addressing patient care, utilization/quality management principals, documentation & regulatory requirements,



  • Certification in health care training/instruction, utilization, or quality management desirable
  • Certified coder desirable




  • Detail oriented, highly organized and creative work skills
  • Demonstrate initiative and perform as a motivated self - starter
  • Excellent written and verbal communication skills
  • Proficient with Microsoft Office products, particularly Word, Power Point and Excel
  • Grasps complexities & perceives relationships among issues to effectively problem solve
  • Willing/able to adjust to multiple demands, shifting priorities, ambiguity & rapid change
  • Shows resilience in the face of constraints, frustrations or adversity
  • Demonstrates flexibility
  • Handles day-to-day work challenges confidently
  • Ability to work well with a team as well as independently
  • Excel in customer satisfaction commitment to continuously provide quality services
  • Demonstrate commitment to company’s mission, culture and values
  • Strong knowledge of healthcare industry principles related to utilization management, quality assurance, regulation and reimbursement
  • Experience with URAC guidelines for Utilization Management
  • Ability to assess, monitor and reinstruct others in the ‘logical’ management of a member’s treatment across the care continuum.
  • Ability to describe, assess, monitor and reinstruct others in the support of a clinical review determination
  • Strong knowledge of coding principles’ influence on payer systems applicable to DRG validation and outlier review
  • Experience in analyzing workflows and outcomes data to identify areas for improvement and/or corrective action
  • Ability to provide instruction across varying levels of education and management experience
  • Strong knowledge of learning styles & effective presentation and instruction methods
  • Ability to remain current and provide department specific updates & feedback to all areas of organizational productivity


Job Responsibilities

This is a partial list of the position responsibilities. A candidate must understand and be willing and able to assume roles and responsibilities in addition to those listed in assuring the specific needs of the department and larger company organization.

  • Is the chairperson and leads all meetings of the Quality Management Committee, spends minimum of 50% of time on quality related issues/monitoring/reporting.
  • Assists Management and other Senior Staff with workflow and productivity analysis in the management of process improvement initiatives.
  • Performs QM activities including quality reviews to meet department & organizational QM program annual QIP goals.
  • Consults appropriately with Management & other Senior Staff members regarding training issues on regulation, documentation improvement, UM /QM principals, revised Milliman and other criteria with commensurate adjustments to or development of new workflows.
  • While working with the Director of UM regarding all UM activities, provides direct monitoring of UM staff to ensure that standards of care and ethical practice, department policies and procedures, compliance regulations, plan benefit information, and Milliman national review criteria are adhered to in making medical necessity determinations.
  • Provides onsite clinical guidance to UM staff on utilization review of prospective, concurrent, and retrospective inpatient and outpatient service requests including reconsiderations and appeals.
  • Serves as a resource to internal and external customers, and providers regarding appropriate utilization of medical services, clarification of policies/procedures, and member benefits
  • Provides support using knowledge of UM and member benefits to work collaboratively with healthcare providers and clients to assure appropriate utilization of services and care transition.
  • Ensure URAC requirements are met and leads URAC training and recertification process.
  • Works with the Senior Medical Director to track, trend, report & support the Physician QM program.
  • Works with the Director of Review Operations and the Sr Director of Coding to track, trend, and report on and provide support of the Coder QM and Nurse QM programs.
  • Identify trends and training opportunities in support of the overall company QM programs.
  • Provides coaching, counseling, and employee development at request of department Director or staff member.
  • Provides liaison support among physician reviewers (Medical Directors), intake coordinators, and nurses and coders to ensure optimal performance.
  • Directs necessary corrective action plans for improvement based on QM monitoring and audits
  • Strictly observes company policies regarding confidentiality of member information and standards of documentation.
  • Routinely checks voicemail and e-mails throughout the day to ensure returned calls/messages on the same day (within 24 hours under extenuation circumstances)
  • Performs other duties as assigned


Company Description
Growing organization.

Pivotal Solutions, Inc.

Why Work Here?

Stable and growing organization.

Growing organization.


Portland, ME