Description

Job Objective:

Under the direction of the Vice President of Quality & Regulatory Affairs, the CMS Quality Strategy & Analytics Program Manager provides strategic leadership, program management, analytics, and performance improvement oversight for Antelope Valley Medical Center's CMS quality programs, publicly reported measures, value-based performance, and other assigned organizational quality initiatives. The position leads the development, implementation, and monitoring of strategies designed to improve CMS quality performance and patient outcomes; translates complex regulatory and quality requirements into actionable operational plans; develops and maintains executive dashboards and key performance indicators; and provides project management for major internal and external quality initiatives. The Program Manager serves as a key liaison among Quality, Information Technology, Finance, clinical and operational departments, external agencies, vendors, and other stakeholders to ensure accurate data, effective project implementation, regulatory reporting, and sustained performance improvement. The overarching objective of the position is to move the organization from retrospective reporting toward a proactive, predictive, and strategically managed approach to CMS and organizational quality performance.

Duties and Responsibilities:

A. AUDITING, COMPLIANCE AND DATA QUALITY

1. Reviews and validates clinical documentation to ensure adverse events including PS ls, HACs and other quality indicators are correctly identified prior to final coding.

2. Generates, evaluates, and distributes various coding and data related reports.

3. Reviews COi and Coding queries for compliance and assists with generating

4. queries.

5. Performs post discharge reviews for clinical documentation, and coding

6. opportunities.

7. Performs coding audits and provides feedback and education to the coders.

8. Performs, participates in, and tracks internal and external audits identifying areas for improvement.

9. Develops action plans, revises guidelines, and educates coders based on the

a. new coding rule identified, new process identified, outliers on PEPPER reports, OIG Guidance, or HCAi changes in collaboration with the Information Systems Support Coordinator-Coder II, Coder IV, Clinical Documentation and Coding Specialist and Coding Manager.

10. Participates in hospital meetings related to clinical data quality and compliance providing data or education as required.

11. Analyze DRG assignments, CC/MCC capture rates and CMI (Case Mix Index)

a. trends. Supports accurate reporting for quality programs (e.g. PSI, HAC, mortality metrics, Medicare Star Ratings).

12. Follow-up and address discrepancies on the various coding data related reports.

13. Keeps abreast of regulatory changes affecting coded information required by Centers for Medicare and Medicaid Services, HCAi, Uniform Billing Requirements, Official Coding Guidelines and others as appropriate.

B. LEADS DEVELOPMENT AND ONGOING MANAGEMENT OF AVMC'S CMS QUALITY STRATEGY

1. 1. Maintains current knowledge of CMS hospital quality programs, measure specifications, reporting requirements, performance periods, public reporting methodologies, and value-based programs
   2. Translates new and revised CMS requirements into organizational priorities, implementation plans, education, and measurable improvement strategies
   3. Provides strategic oversight and performance analysis for applicable programs including:

• CMS Overall Hospital Quality Star Ratings
• Hospital Inpatient Quality Reporting Program
• Hospital Outpatient Quality Reporting Program
• Hospital Value-Based Purchasing
• Hospital Readmissions Reduction Program
• Hospital-Acquired Condition Reduction Program
• eCQMs and hybrid measures
• Hospital harm and patient safety measures
• HCAHPS
• Mortality and readmission measures
• Healthcare-associated infection measures
• Maternal/perinatal measures
• Age-Friendly Hospital measures
• Health equity measures
• Other current or emerging CMS quality programs

1. 1. Identifies measures presenting significant organizational performance opportunities or risks and develops recommendations for intervention
   2. Partners with Finance to understand and communicate the relationship between quality performance and applicable CMS reimbursement programs

C. QUALITY ANALYTICS & PERFORMANCE INTELLIGENCE

1. 1. Develops, maintains, and enhances organizational quality dashboards, scorecards, and performance reports
   2. Performs trend, variance, benchmark, drill-down, and comparative analyses to identify performance gaps and improvement opportunities
   3. Develops forecasting methodologies to evaluate how current organizational performance may affect future CMS publicly reported results and value-based performance
   4. Establish baseline performance and appropriate targets for assigned improvement initiatives
   5. Develops and maintains operational definitions for internal and external Key Performance Indicators (KPIs) and ensures definitions and methodologies are applied consistently across reporting processes
   6. Validates data accuracy and works collaboratively with departments to investigate discrepancies or unexpected variation
   7. Converts complex quality and regulatory data into concise, meaningful information for executives, physicians, nursing leadership, committees, and operational teams
   8. Develops executive-level dashboards and presentations identifying:

• Current performance
• Trends
• Benchmarks
• Risks
• Improvement priorities
• Intervention status
• Accountable owners
• Expected outcomes

1. PROJECT & PROGRAM MANAGEMENT
2. 1. Manages multiple internal and external quality projects simultaneously, including CMS initiatives, special designations, quality collaboratives, performance improvement initiatives, and other projects assigned by the Vice President of Quality & Regulatory Affairs.
   2. Provides project management with minimal oversight, including management of day-to-day project operations, work plans, timelines, deliverables, status reports, and performance targets.
   3. Develop formal project charters and implementation plans identifying:

• Project objectives
• Scope
• Baseline performance
• Responsible parties
• Interventions
• Deliverables
• Timelines
• Milestones
• Outcome measures
• Sustainability plans

1. 1. Coordinates multidisciplinary project teams and ensures assigned actions are completed within established timelines.
   2. Identifies barriers, competing priorities, and resource needs that may affect project success and escalates significant concerns to leadership.
   3. Leads project meetings and communicates project goals, challenges, progress, and expected outcomes.
   4. Plans and completes projects ranging from complex strategic and analytical initiatives to operational activities necessary for successful implementation.
   5. Evaluates project effectiveness and identifies opportunities to improve team, workflow, or system performance.
   6. Maintains appropriate project documentation to demonstrate implementation, monitoring, outcomes, and sustainability.

E. DATA SYSTEMS & INFORMATION TECHNOLOGY LIAISON

1. Serves as a Quality department liaison with Information Technology and applicable information systems teams regarding quality data, reporting, dashboards, and data infrastructure.

2. Supports management and optimization of data systems utilized by Quality Management.

3. Works collaboratively with IT, clinical informatics, HIM, and operational departments to develop or enhance data capture and reporting processes.

4. Assists with validation of automated reports, dashboards, data feeds, and measure logic.

5. Identifies opportunities to automate manual quality reporting and improve data availability, accuracy, and efficiency.

6. Participates in development of data requirements for new quality initiatives and CMS measures.
7. Supports implementation and testing of technology solutions affecting CMS quality measurement and organizational performance reporting.

E. REGULATORY & EXTERNAL REPORTING SUPPORT

1. Coordinates or supports submission of assigned data and reports to external and/or regulatory agencies as approved by the Vice President of Quality & Regulatory Affairs.

2. Maintains awareness of applicable submission deadlines and ensures assigned reporting responsibilities are completed timely.

3. Coordinates review and validation of CMS preview reports and other applicable external quality reports.

4. Investigates potential discrepancies in externally reported performance data and coordinates appropriate follow-up.

5. Supports validation of organizational quality information appearing on CMS Care Compare and other applicable public reporting platforms.

6. Maintains appropriate documentation supporting external reporting, validation activities, and corrective actions.

F. PERFORMANCE IMPROVEMENT

1. Leads and facilitates multidisciplinary performance improvement initiatives related to identified CMS and organizational quality priorities.

2. Utilizes appropriate improvement methodologies including PDSA, root cause analysis, process mapping, Lean principles, and other recognized quality improvement methodologies.

3. Works collaboratively with clinical and operational teams to move identified opportunities from data ? analysis ? intervention ? implementation ? measurement ? sustainability.

4. Evaluates the effectiveness of interventions and recommends modification when desired outcomes are not achieved.

5. Establishes ongoing monitoring processes to ensure improvements are sustained.

6. Identifies opportunities to improve organizational systems and processes based upon data, regulatory requirements, and observed performance.

H. EXECUTIVE & COMMITTEE REPORTING

1. Prepares concise executive-level reports regarding CMS performance, emerging requirements, organizational risks, and improvement activities.

2. Presents performance data and project updates to appropriate committees, leadership groups, and multidisciplinary workgroups as needed.

3. Supports CMS-related reporting through the organization's QAPI/PIPS structure.

4. Provides the Vice President of Quality & Regulatory Affairs with timely notification of significant performance concerns, regulatory changes, project barriers, or emerging risks.

5. Develops recommendations supported by data and analysis to facilitate leadership decision-making.

I. SPECIAL PROJECTS

1. Provides project leadership for strategic Quality initiatives assigned by the Vice President of Quality & Regulatory Affairs.

2. Supports implementation of innovative care models, quality collaboratives, demonstration projects, special designations, and other organizational initiatives as assigned.

3. Conducts research, analysis, project development, and implementation activities necessary to support emerging organizational priorities.

4. Assumes responsibility for special projects that require significant coordination among Quality, clinical operations, information systems, Finance, regulatory agencies, vendors, or external partners.

Knowledge, Skills and Abilities: Knowledge
• Advanced analytical and critical-thinking ability.
• Strong understanding of healthcare quality and performance improvement.
• Ability to interpret complex CMS regulations, technical specifications, and quality-measure methodology.
• Ability to translate technical requirements into practical operational strategies.
• Strong project and program management skills.
• Advanced proficiency in data analysis and visualization.
• Ability to develop meaningful dashboards and executive scorecards.
• Ability to identify trends, variation, outliers, and performance opportunities.
• Strong proficiency with Microsoft Excel and PowerPoint.
• Ability to learn and utilize hospital quality analytics and reporting platforms.
• Strong written and verbal communication skills.
• Ability to facilitate multidisciplinary teams and drive accountability without direct supervisory authority.
• Ability to manage multiple high-priority initiatives simultaneously.
• Strong attention to data integrity and detail.
• Ability to independently identify opportunities and move initiatives from analysis to action.
Skills
• Project management tools and techniques (eg.MS Project)
• Microsoft Office (Outlook, Word, Excel, PowerPoint and Visio)
• Excellent oral and written communications skills required
• Excellent organizational skills
Abilities
• Ability to manage projects within schedule, scope, resource and budget constraints.
• Ability to select and supervise project team staff and create and maintain group cohesiveness.
• Ability to communicate to all levels in an organization from front line staff through executive management.
• Ability to work effectively with cross functional groups and participate in problem solving process
• Ability to work effectively and efficiently with minimal supervision.