Job Details

Overview

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Summary Of Position

Implement, track, and report on performance improvement initiatives, on measures that directly impact EmblemHealths rankings on the quality rating programs. Collaborate with the leadership of Provider Network and Product, Analysts, Member facing departments, IT and other cross functional teams to align strategies and quality improvement priorities in contracting, vendor relationships, sales and product development, and procurement. Identify improvement opportunities and provide guidance for needed changes. Manage the provider quality strategy, including implementation of key initiatives. Develop, manage, and report on various quality provider facing programs including the Provider P4P Program (QIP), various VBP arrangements. Manage and monitor Quality Improvement metrics in collaboration with department leadership to ensure that gains are maintained, and corrective actions are taken as necessary to ensure performance improvement and to support compliance with HEDIS, QARR, and Star processes across all regions where we have membership.

Responsibilities

• Responsible for managing the Quality Execution Team, to drive identification and execution of initiatives to increase EmblemHealths quality ratings (Medicare Stars, Quality Incentive Awards, Quality Rankings, Accreditation Status) and ensure compliance with NCQA, state and federal regulations and requirements.
• Implement the Member Rewards Programs.
• Track, monitoring and analyzing initiative key performance indicators and performance on various quality measures i.e. HEDIS/QARR, including analysis of trends in performance against national and regional benchmarks.
• Partner with internal departments, external vendors and medical groups to improve or maintain healthcare quality metrics and outcomes.
• Develop and manage Quality education materials and tools for providers and vendors.
• Educate company teams on the importance of measures for improving quality ratings and understand their current strategies and plans to improve performance on those measures.
• Manage the Provider Incentive Program (QIP) across the enterprise to drive improved quality performance of network providers.
• Support various VBP contracts by owning the quality and member satisfaction sections.
• Manage various quality collaborative efforts/initiatives with key provider groups.
• Manage relationship with provider engagement team and attend JOCs representing quality.
• Lead selected quality improvement committees, subcommittees and workgroups to support process improvement activities. Review and update operational processes relating to quality management activities. Define and document newly established processes.
• Support preparation, organization and follow-up in acquiring and maintaining NCQA accreditation and compliance with local, state and federal regulatory authorities, includes support of the health plans HEDIS, QARR, and Star processes.

Qualifications

• Bachelors Degree in a health services field or related required. Advanced degree preferred.
• Six Sigma Green or Black Belt preferred.
• 5 8+ years of relevant, professional work experience, preferably in a healthcare provider environment.
• 3 5+ years of managed care experience in government sponsored insurance programs.
• Experience with HEDIS, QARR, CAHPS and HOS requirements.
• Knowledge of/experience with quality/process improvement techniques (e.g., PDSA); redesign, etc.
• Strong organizing, prioritizing, analytical, problem identification and solving, and decision-making skills.
• Ability to deal with ambiguity and to interact with all levels of management.
• Ability to collect, organize and present data in a clear and concise manner and to use data analytics tools.
• Ability to assess all work and prioritize as necessary to meet reporting timeframes and deadlines.
• Proficient with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, SharePoint, etc.).
• Staff/team management experience.
• Proven project/program management experience.
• Excellent communications skills (verbal, written, presentation, interpersonal) with all types/levels of audiences.

Additional Information

• Requisition ID: 100#######
• Hiring Range: $77,760-$149,040

Job Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Quality Assurance
• Industries: Insurance