Job Description

Your Role

The Program Manager, Senior, Quality Improvement is responsible for the development and execution of targeted, quality improvement initiatives in support of the Medi-Cal line of business, contributing to improved performance on various quality rating systems including, but not limited to, Healthcare Effectiveness Data Information Set (HEDIS), Managed Care Accountability Set (MCAS), Consumer Assessment of Healthcare Providers and Systems System (CAHPS), National Committee for Quality Assurance (NCQA) Health Plan Ratings, Department of Managed Health Care (DMHC) Health Equity Quality Measure Set (HEQMS), and Medicaid Quality Rating System (QRS). This includes the design, development and management of provider group quality interventions, toolkits, clinic days and gathering analytic insights with the quality data. The Program Manager also has accountability for aligning quality improvement initiatives with other lines of business (Commercial, Medicare) and for ensuring that current and future QI programs align with long-term organizational strategies.

In a results-oriented environment, the Program Manager will execute quality improvement efforts, incentive strategies, and new improvement tactics to bring additional value to integrated health benefits. To do this, the Program Manager is expected to coordinate with internal, cross-functional matrix teams, as well as with clinical leadership and staff in provider organizations.

The Program Manager will be responsible for participating in project teams and working with external vendors, assigning and monitoring work of team members, and providing guidance and leadership to ensure timely execution of deliverables. This position may include limited accountability for managing budgets.

In partnership with the Medi-Cal team, the Program Manager will support in-person clinic days across San Diego County that are held at Community Based Organizations; this may include occasional evening and weekend commitments. The Program Manager will also be accountable for building strong, collaborative relationships with targeted provider organizations. The Program Manager is responsible for developing and managing communications about Blue Shield of California Promise Health Plan quality improvement initiatives through the development of RFI responses, Medi-Cal contracts, toolkits, and other ad hoc assignments. Additionally, this position organizes interdepartmental activities and has some operational responsibilities.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

This role is a hybrid field worker. This person will be required to be in the San Diego office or out visiting clinics 5 days per month minimum in the San Diego area. On average, there are 1-2 clinic days per week. In addition to this there could be evening hours or Saturday hours.

Responsibilities

Your Work

In this role, you will:

• Responsible for planning, execution, and evaluation of large and complex program initiatives to improve quality performance in the Medi-Cal line of business.
• Develops and monitors measurement strategies for large change and improvement initiatives.
• Manages program(s) from initiation/pilot phase through delivery/spread and monitors for continuous improvement.
• As part of a broader QI team, influences the business unit, strategies, and objectives.
• Becomes an expert in company quality initiatives, as well as the products, functions, marketing, and/or service policies and procedures that support those initiatives.
• Serves as a quality expert with internal constituents to drive successful improvement initiatives in the Medi-Cal line of business.
• Leads and supports interventions to improve performance on HEDIS, MCAS, CAHPS, NCQA Health Plan Ratings, DMHC HEQMS, and Medicaid QRS.
• Leads in-person community-based clinic days at Community Based Organizations in San Diego County (3-6 days a month or as scheduled).
• Educates and works with external partners and participating practices as needed to identify innovation opportunities and adopt improvement actions. Partners with providers, in-person, at clinic locations to identify practice barriers and areas for improvement.
• Exercises independent judgment in developing methods, techniques, and evaluation criteria for obtaining results.
• May assist in the planning and direction of budgets.
• May act as the business unit liaison to corporate initiatives and projects.

Qualifications

Your Knowledge and Experience

• Requires a college degree or equivalent experience.
• Requires a minimum of 5 years of prior relevant experience.
• Requires at least 5 years of healthcare experience in Quality Improvement and Quality Management with knowledge in these specific areas: quality improvement, process improvement, practice transformation techniques.
• At least 5 Years of Medicaid/Medi-Cal experience required.
• 3 years working with IPAs, medical groups, FQHCs, and/or providers required.
• Previous project/program management experience required.
• This role is a hybrid field worker. This person will be required to be in the San Diego office or out visiting clinics 5 days per month minimum. On average, there are 1-2 clinic days per week. In addition to this there could be evening hours or Saturday hours.
• Knowledge of HEDIS and accrediting body requirements (e.g., NCQA) desired.
• Proficiency with Cozeva application highly desired.
• Tableau for quality reporting is preferred.
• Experience with review of medical records to identify service compliance and missed opportunities preferred.

Hybrid- Field Worker

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

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