Under the direction of the SeniorDirector of Quality and Compliance, theDirector has broad responsibility for managing the quality agenda for Health and Medical Management. TheDirector is also accountable for HMM’s strategic direction regarding quality and is accountable for external measurement improvement including HEDIS/HOS for commercial/Medicare5 Stars, and FEP QCR Program. TheDirectorcollaborateswith BCBSMADirectors and Vice Presidents in multiple divisions including Performance Measurement & Improvement, Provider Contracting HMM, Medicare, and FEP to meet key strategic and quality objectives
- Sets strategic direction for health management initiatives intended to improve or maintain NCQA standing as well as CMS STAR rating, and FEP quality ratings
- Develops the HMM Quality Work Plan, and in collaboration with the Senior Director of Quality/Compliance and Cost and Trend & VP of Clinical Operations sets strategies and operational plans to meet the work plan
- Leads Health and Medical Management (HMM) Quality Team and directs Quality Activities.
- Directs best practices analyses, benchmarking and research on quality and regulatory clinical programs and innovations to support BCBSMA’s continued compliance with third party reportable metrics Oversight of performance improvement activities and related clinical and non-clinical quality improvement/ performance improvement activities that are aligned with HMM’s business goals
- Works in consultation with HMM Business Units to develop provider performance measurement programs, based on quality, utilization and cost data, to ensure consistent delivery of cost-effective, high quality behavioral health care for members
- Leads the oversight of HM delegated vendors(s) that provide integrated Health Management services to BCBSMA Member
- Chairperson of Behavioral Health Quality Coordination Committee including annual reporting and analysis of all BH Quality Initiatives
- Provide leadership for new or on-going quality initiatives developed by Health Management related to Quality Improvement and identifies/ create appropriate cross-functional teams to implement these initiatives.
- Develop and oversee Government Programs Quality Improvement Plan.
- Strategic Direction of Medicare Quality Program for HMM including but not limited to Quality Improvement Projects (QIP), Chronic Care Improvement Program (CCIP), and HM Stars Programs
- Accountable for FEP Quality Improvement Plan. Develops and implements metrics to monitor quality and regulatory processes in HMM including rapid cycle quality improvement as required.
Qualifications (Knowledge, skills and abilities):
- Demonstrated success in working in a collaborative manner at all levels of an organization to achieve outcomes that require building consensus and expedited implementation.
- Demonstrated ability to influence and negotiate outcomes which may be controversial and/or sensitive
- Demonstrated understanding and implementation of clinical quality improvement principles and ability to creatively link these principles to development and implementation of collaborative quality initiatives
- Demonstrated planning ability; setting strategies and following through to implementation
- Requires initiative and highly developed verbal and written communication, interpersonal, planning and analytical skills and ability to develop and integrate projects into operations
- Must be able to negotiate project requirements/ responsibilitieswith multiple departments and vendors and coordinate all functions to achieve timely project development and completion
- Demonstrated knowledge and experiencewith measurement/data analysis
- 10 years managing accreditations or Quality for large clinical divisions required
- Registered nurse or Clinical Professional with active professional Massachusetts license or equivalent managed care industry experience
- 5years clinical experience or in managed care environment/industry
- 10 years’ experience in quality improvement management
- Bachelor’s Degreerequired/Master's degree in Public Health, Business or Health Care Administration or an equivalent (as determined by BCBSMA) is preferred
- CPHQ certification plus