Implements an all product quality management strategy that meets internal and external constituent expectations for demonstrating quality outcomes. Using innovation, integration, and information links the quality management activities to business goals. Health Care Quality Management includes, but is not limited to, HEDIS, QM Programs/Infrastructure, behavioral health QM, credentialing, delegation and regulatory accreditation support, clinical and service measurement and improvement and quality of care investigations.
Accountable for HEDIS health care quality projects and initiatives through direction setting and leadership. Assimilates information to proactively develop quality activities aligned with company strategies and values. Links the quality management activities to business goals. Proactively builds strong teams and business relationships, both internally and externally. Serves as a resource and subject matter expert (SME) on aspects of the quality program to develop and influence business strategies.
Makes business decisions based on the results of research and data analysis.
Has responsibility for decision making regarding the design, development, and implementation strategy of HEDIS quality improvement projects, and initiatives.
May manage a QM functional department including development and oversight of HEDIS performance metrics and application of HR policies and procedures.
Forms and leads cross functional teams to assist business units in integrating quality into their strategic and operational plans.
Evaluates and prioritizes recommendations for quality improvement to senior management and/or customers.
Partners with sales and marketing across all segments in their efforts to acquire and retain customers (e.g. responding to RFPs), quality presentations, request for measurement information.
Develops and implements the infrastructure of the QM program and Patient Safety strategy.
Develops, implements, and evaluates the HEDIS organizations policies and procedures to meet business needs.
Directs/provides enhancements to business processes, policies and infrastructure to improve operational efficiency across the organization.
Influences department business owners and leaders to reach solutions to meet the needs of Plan Sponsors, regulators and other customers while meeting departmental objectives.
Provides comprehensive analysis of HEDIS measures, barriers and opportunities and present results of improvement efforts and ongoing performance measures to management.
Manages all clinical quality metrics, HEDIS processes and results
In partnership with business owners, supports design /development of new or enhanced products and services.
Translates knowledge of HEDIS and business needs into clear strategic business plans.
Serves as a technical, professional and/or business expert that may cross multiple business functions.
6+ years progressive experience in operational quality management roles in the healthcare industry, regulatory environment and quality management.
Previous HEDIS experience; computer literate with advanced proficiency in MS Office Suite applications and keyboard navigation skills.
Demonstrated leadership ability.
Education and Certification Requirements:
Bachelor's degree, Nursing degree, or other comparable healthcare experience.
Understanding of trends and constituency expectations.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN) is desired
Functional - Quality Management/Quality Management/7-10 Years
Desktop Tools/Microsoft Word/4-6 Years/End User
Desktop Tools/TE Microsoft Excel/4-6 Years/End User
Desktop Tools/Microsoft Outlook/4-6 Years/End User
Desktop Tools/Microsoft SharePoint/4-6 Years/End User
Benefits Management/Maximizing Healthcare Quality/ADVANCED
Finance/Delivering Profit and Performance/ADVANCED
Finance/Profit and Quality Vigilance/ADVANCED
General Business/Demonstrating Business and Industry Acumen/MASTERY
General Business/Consulting for Solutions/MASTERY
General Business/Communicating for Impact/ADVANCED