Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.)

Job Summary

The Clinical Quality Program Manager is responsible for identifying, implementing, and guiding projects relating to quality excellence in Centers for Medicare and Medicaid Services (CMS) Five-Star Rating System and Marketplace Exchange Quality Rating Systems (QRS). The position is responsible for strategizing quality improvement programs and ongoing management using a data-driven focus that sets priorities for improvements aligned with ongoing strategic initiatives. This position collaborates with the Quality Improvement/ Quality Performance Management QI/QPM and Health Information Management (HIM) analytics support, Risk Adjustment, other plan operations business units, and network providers to strategize and promote success in achieving L.A. Care's enterprise wide quality goals and initiatives.

The Clinical Quality Program Manager develops and tracks the work plans, identifies and implements short and long-term intervention and programs that support goals to improve quality program ratings, provides oversight in the deployment and evaluates the effectiveness. This role also tracks, manages, and reports project progress and outcomes. Manage vendor contracts. Facilitates collaboration with internal and external stakeholders to ensure the full integration of initiatives throughout the organization.

The Clinical Quality Program Manager is a subject matter expert (SME) on Clinical Quality programs, interventions and quality metrics related to Medicare Stars or Covered California QRS programs. These programs include metrics that support Consumer Assessment of Healthcare Providers and Systems (CAHPS) and / or Health Outcome Survey (HOS) and /or Healthcare Effectiveness Data and Information Set (HEDIS), Medication Adherence and Plan Operations and /or other domains of focus such as Pharmacy and /or Administrative / Regulatory.

Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.

Duties

Develop and maintain clinical quality work plans, convene committees and workgroups, and assist. Leads the Core Teams by leveraging technology and tools to streamline processes, enhance collaboration and synergy, promote data sharing, and improve transparency across clinical and operational areas.

Drive collaboration, education, training, and maintaining working relationships across the Core teams with multiple departments throughout LAC including but not limited to QI, Pharmacy, Care Management, Utilization Management, Risk Adjustment, Products, Customer Solution Center (CSC), reporting and Analytics, Appeals and Grievances and the provider network.

Manage and maintain the SharePoint sites to ensure all guidance from regulatory entities are available to key stakeholders and that enterprise-wide activities are documented and shared among accountable entities and network providers.

Coordinate workgroup meetings; send meeting reminders, format agendas, minutes and handouts. Manage the team SharePoint site. Follow up on meeting action items.

Duties Continued

Work closely with QI, Health Services, Reporting/Analytics, vendors, and the provider network on shared quality initiatives, data sharing and analyses.

Monitor/track enterprise wide quality intervention and analytical strategies that elevate quality of care and enhance satisfaction for LAC members.

Work closely with Core Team of Analytics to lead quality reporting and analytical strategies to enable accountable entities and stakeholders to drive quality ratings improvement for Consumer Assessment of Healthcare Providers and Systems (CAHPS) and / or Health Outcome Survey (HOS) and /or Healthcare Effectiveness Data and Information Set (HEDIS), Medication Adherence and Plan Operations and /or other domains of focus such as Pharmacy and /or Administrative / Regulatory or other QRS specific metrics.

Assist with identifying measures that need performance improvement, evaluate data, coordinate discussion/workgroup to develop strategy and work plan.

Research and implement best practices to improve population health, quality of life and evaluate impact.

Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project's/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Perform other duties as assigned.

Education Required

Bachelor's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Master's Degree in Public Health or Related Field

Experience

Required:

At least 5 years of experience in a health plan specializing in healthcare quality, informatics, QI initiatives and analytics.

Experience in implementing initiatives to improve quality ratings and managing projects and programs end to end.

Preferred:

Experience in a health plan specializing in Consumer Assessment of Healthcare Providers and Systems (CAHPS) and / or Health Outcome Survey (HOS) and /or Healthcare Effectiveness Data and Information Set (HEDIS), Medication Adherence and Plan Operations and /or other domains of focus such as Pharmacy and /or Administrative / Regulatory or other QRS specific metrics

Experience in implementing initiatives to improve quality ratings and managing projects and programs end to end for the above-specified metric sets.

Skills

Required:

Thorough knowledge on health plan quality ratings including Medicare Stars and / or Marketplace Exchange Quality Rating Systems (QRS).

Demonstrated analysis skills.

Must possess aptitude for accuracy and attention to details.

Proficient in Microsoft Office tools.

Ability to present data and analysis in a meaningful way, tailoring the message with audience in mind.

Excellent verbal, written and presentation skills.

Demonstrated critical thinking, problem-solving and process improvement skills.

Independent judgment and action skills to facilitate change as needed.

Knowledge of managed care industry standard performance assessment methods.

Able to work in a team environment, with good communication skills, supportive attitude and the ability to provide mentorship when appropriate.

Must demonstrate ability to work collaboratively and seek solutions proactively applying critical thinking skills in evaluating priorities and solutions.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Light

Additional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offers a wide range of benefits including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)