Job Description

Job Summary

Oversee and actively participate in quality improvement projects. Contribute to the overall success of Quality Programs by promoting /advancing the department mission of effectively managing members and improving health outcomes. Serve as the Quality Management liaison for internal and external partners for projects and improvement initiatives. Subject matter knowledge expert with regards to quality improvement & reporting.

Responsibilities

• Work directly with business partners to plan, implement, and oversee ongoing operational execution of quality improvement projects and action plans (HEDIS, CAPHS, and HOS) to meet corporate business goals for Medicare, Medicaid, QHP, and Commercial product lines.

• Support the execution of centrally developed and data-driven strategic plans.

• Assist in leading cross-functional teams for collaboration on HEDIS, CAHPS, HOS, Pharmacy, and Enterprise metrics.

• Serve as a point of contact for quality vendors: develop and share target lists; provide support in monitoring performance against established Service Level Agreements; provide a communication bridge between the company/line(s) of business and the vendors.

• Manage ongoing quality programs including Member Rewards & Incentives, Provider Quality Incentives, and addressing Health Disparity initiatives.

• Provide subject matter expertise and support on all quality metrics to key stakeholders.

• Support NCQA/CMS/HEDIS/CAHPS/HOS and other regulatory requirements that apply to quality programs.

• Work with the data team to conduct analysis and reporting as needed on initiatives designed to impact quality performance to provide insight to future projects.

• Develop annual performance improvement projects; analyze project data; and ensure completion of the finished product(s) including the development of year-end report(s).

• Develop methodologies for quality program assessment (ROI and proof points of program outcomes, etc.)

Qualifications

• Bachelor’s Degree; Master’s Degree (Strongly Preferred)

• Project Management/Vendor Management certification (Preferred)

• 5 – 8 years of relevant, professional work experience (Required)

• 3 – 5 years of Quality and/or program management experience in a managed care organization (Required)

• Additional years of experience/specialized training/certifications may be considered in lieu of educational requirements (Required)

• Experience in researching, developing, implementing, and assessing results of metrics and analytics (Required)

• Understanding of contractual or compliance related SLAs (Required)

• Ability to successfully manage multiple projects/tasks with competing priority levels and deadlines (Required)

• Experience and knowledge with HEDIS/QARR, CAHPS, CMS Star Ratings, and Accreditation (Required)

• Proficient in MS Office - Word, PowerPoint, Excel, Outlook (Required)

• Excellent communication skills - verbal, written, presentation, interpersonal, active listening (Required)

• Working knowledge of MS Access (Preferred)

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