Who you will be working with:
This position supports the quality functions for Evolent’s clients as he/she (1) designs, builds and manages health plan quality programs that meet CMS and NCQA requirements; and (2) sets strategy, monitors, and optimizes QI initiatives for performance-based payment programs, such as Medicare Advantage Stars Ratings and CMS ACO Shared Savings Program; (3) coordinates care gap closure efforts with other physician-facing initiatives.
The Director, Quality Improvement plays a key role with the respective client team in creating infrastructurerequired for performance monitoring and quality improvement purposes, as well as strategies for raising performance on national measures of population health management.
For the assigned client, the Director, Quality Improvement will drive the customization, launch and ongoing operations of the Proactive Care program, a multi-pronged approach to identifying and closing important gaps in care for patient populations.
What You’ll Be Doing:
- Identify and prioritize key quality and utilization measures critical to client success under its performance based payment programs.
- Work closely with the market team’s Medical Director, Senior Director of Clinical Operations, and other key leadership. Support Proactive Care program’s outreach to physician practices through customization of measures tool/report and collection and analysis of physician feedback data.
- Introduce processes to track measure performance toward goals, and based on findings, engage Evolent and client clinical leadership in discussion of potential improvement interventions
- Collaborate with Evolent clinical leadership, Program Innovations team, Clinical Informatics, and Reporting to operationalize care gap closure efforts for the client
Health Plan Quality Programs
- Manages the health plan quality improvement program description (QIPD) the annual evaluation and workplan.
- Prepare and present reports for internal and external client committees (e.g., QIC, Credentialing); prepare and maintain minutes; maintain, review and participate in the revision of departmental and corporate policies, procedures and protocols.
- Manage the implementation and successful completion of Medicare and Medicaid quality improvement program projects including, but not limited to HEDIS, Chronic Care Improvement Program (CCIP) and Quality Improvement Projects (QIP), and other performance improvement initiatives and CMS-mandated projects.
- Oversee the tracking, trending and reporting of internal and external quality management data for client health plan
- Assure initial and on-going compliance with state and federal quality improvement requirements; specifically from Chapter 5 of the Medicare Managed Care Manual.
- Assist in the implementation of review/audit plans, self-assessments and other activities to monitor and track ongoing compliance with NCQA standards, federal and state laws, and Medicare/Medicaid rules and regulations.
- Coordinate aspects of the audit program, including maintaining audit files, developing an audit timeline, analysis of audit data, and accurate reporting of all audit results.
- As needed, facilitate NCQA readiness review activities to ensure all accreditation requirements are met.
- Coordinate activities between RAF and Proactive Care to ensure seamless, efficient experience for participating physicians
The Experience You Need (Required):
- Clinical training and Masters in health-related field desirable
- Past health plan or managed care environment highly preferred, including minimum of two years Medicare and/or dual eligible quality management experience in a managed care setting
- 5+ years clinical and/or health care management experience, with general understanding of performance measures (e.g., NCQA/HEDIS measures, MSSP measures, etc.)
- Knowledge of QI/CQI principles, CMS requirements and regulations, and NCQA standards and regulations
- Experience with analyzing HEDIS, CAHPS, HOS and Medicare Star rating data.
- Excellent analytical, verbal, written, organizational and interpersonal skills.
- Intermediate level proficiency with Microsoft Office applications and data management reporting.