Under direction to plan, develop, implement, and coordinate the operation of the Quality Management/Risk Management (QM/RM), Utilization Management (UM) and Patient Education Services and Valley Connection (Registration/ Scheduling and Advice), Referral Center, Language Services and Staff Development Programs for Ambulatory and Community Health Services as well as, Quality Management and Health Education Services for Valley Health Plan.
Valley Health Plan (VHP) was licensed in 1985 to provide a choice for County of Santa Clara employees and grew to 4,500 members by 1995. We are now a health plan choice for medical care for employer groups, Covered California, and VHP's Individual & Family Plan. It is through our mission, vision and values that we provide quality service and health care to our members.
Valley Health Plan is dedicated to helping members get the care and service they need, at the right time, at the right place, by the right provider. As the only locally-based health plan in Santa Clara County, we understand the needs of our members. Serving the community for over 30 years, we know our providers and can help find the best fit for our members health care needs. VHP offers a quality network of primary and specialty care providers, convenient nationwide pharmacies as well as select local pharmacies, and free health education classes focused on nutrition and fitness, as well as a variety of chronic disease prevention and management programs.
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Learn more about Santa Clara Valley Medical Center: Hospital and Clinics at www.scvmc.org and follow us on:
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- Assesses QM/RM, Utilization Management/Case Management component of the Valley Medical Center operation by reviewing current practices, and gathering, compiling and evaluating data related to employees, service problems reported and patient feedback;
- Directs the operation of registration, scheduling and advice services with Valley Connection to Valley Medical Center patients, Valley Health Plan members (24 hours a day/7 days a week, and Community Health Partnership patients for after hours care;
- Directs the development, coordination and evaluation of the Disease Management Services in the Ambulatory & Community Health care setting;
- Directs the planning, development, implementation and evaluation of Patient Education Programs for Ambulatory & Community Health Services and Valley Health Plan;
- Provides administrative oversight of Language Services within Santa Clara Valley Health and Hospital System;
- Directs the development of an annual evaluation of the QM/ RM/ UM Programs for Ambulatory Services, QM program for the Valley Health Plan and initiates process to improve programs based on the evaluations;
- Directs the planning, preparing, and compiling of reports/written responses for Federal and State regulatory agencies and Joint Commission on Accreditation of Health Care Organizations (JCAHO);
- Regularly makes visits to the Outpatient/ Health Clinics throughout the County of Santa Clara to oversee, promote and provide guidance in the monitoring of compliance with federal, state, Department of Managed Healthcare and JCAHO standards;
- Supervises site visits to Valley Health Plan provider locations to ensure regulatory compliance with managed care regulatory requirements;
- Develops, implements, and ensures that policies and procedures for standard patient care are maintained at clinics and other facilities through out the County of Santa Clara;
- Directs the planning implementation and evaluation of programs designed to enhance nurse manager and staff knowledge of care standards, changes in laws/ regulations, and QI/RM findings and to enhance staff knowledge on various related topics;
- Collaborates with clinical and administrative staff to develop monitoring methods and forms to facilitate patient management, clinic/ department safety evaluation, performance appraisal and tracking of data necessary for quality improvement and reporting;
- Maintains competence and knowledge of current trends in healthcare delivery standards, compliance, regulatory and accreditation topics related to ambulatory care delivery and managed health care;
- Selects, trains, supervises, coordinates, and evaluates, the work of subordinate professional. administrative and clerical staff;
- Participates in continuing education activities for professional growth, licensure and certification requirements;
- Regularly communicates and coordinates/acts as liaison with managers throughout Valley Medical Center, regulatory agencies, relevant professional associations, County Counsel, and other County agencies;
- Collaborates with agency/ hospital-wide QI/ RM departments;
- Reviews and recommends departmental budgets submitted by department managers to implement stated objectives;
- Initiate and/or participate in research related to standards, quality improvement, and risk management;
- Directs the operation or registration, scheduling and advice services within Valley Connection to VMC patients, VHP members and Community Health Partnership patients;
- Directs the planning, development, implementation, and evaluation of Patient Education Program for Ambulatory & Community Health Services and Valley Health Plan;
- Directs development, coordination and evaluation of Disease Management Services in the Ambulatory Care;
- Provides administrative direction for the delivery of referrals and authorizations for specialty services;
- Initiates new programs and approaches to the delivery of Ambulatory Care Services;
- Perform other related tasks as required.
Possession of a license as a Registered Nurse issued by the California Board of Registered Nursing, and the abilities and current knowledge to perform the typical tasks of this position in a multiple location Ambulatory Services Program and managed care delivery system.
A typical way to obtain the required knowledge and abilities would be possession of a Baccalaureate Degree in nursing or related field and a minimum of three (3) years of ambulatory care nursing experience with a minimum of one (1) year in an administrative or supervisory capacity within an ambulatory care/managed care setting. Possession of a valid California driver's license upon appointment.
- Nurse Practice Act;
- Federal legislation regarding compliance, HIPAA, and managed healthcare;
- Principles and practices of ambulatory care, clinical systems and quality improvement, infection control, and safety;
- Current trends in QI/ RM issues, emergency and ambulatory care fields;
- Program management within emergency and other ambulatory services settings, including planning, implementation, evaluation, and reporting laws, codes and regulations;
- County, state and federal legislation applicable to contemporary nursing, emergency treatment, and other patient care issues, resources for researching legislative issues;
- Organization and function of emergency departments and ambulatory care clinics, organizational, personnel and fiscal management within a health care facility/ agency;
- Healthcare systems operations;
- Concepts and practice of centralized healthcare registration/ scheduling and advice services.
- Organize, direct, coordinate, and evaluate clinical services to ensure quality patient care and conformity with prescribed laws, regulations, and standards;
- Work cooperatively with administrators, medical personnel, nursing staff and others to obtain and evaluate information, and implement changes for QI/ RM;
- Effectively train staff in QI/ RM principles and practices;
- Prepare complex and detailed written reports and procedures;
- Develop and analyze data and maintain accurate records;
- Maintain up-to-date knowledge of nursing practice, quality assurance trends/practices, risk management and current legislation;
- Communicate effectively at all levels within Ambulatory Services and with other departments/ agencies and the public;
- Direct Ambulatory Care Service departments and provide integration and support services for clinical operations at multiple locations.