Resp & Qualifications PURPOSE: Plan, organize, and lead teams and initiatives to improve enterprise quality performance, healthcare analytics, and HEDIS outcomes across health plan populations. Develop and execute data acquisition, quality analytics, and multi-year quality improvement strategies that enhance member outcomes, customer satisfaction, and quality of care. Provide oversight of quality vendor management, medical record retrieval and validation, accreditation support, regulatory and state reporting, provider performance reporting, and cross-functional scorecard development. Ensure the accuracy and integrity of quality performance reporting while maintaining audit readiness and compliance with NCQA, regulatory, and organizational standards. Champion continuous improvement through the measurement, monitoring, and optimization of processes that drive operational excellence, HEDIS performance, Stars ratings, and regulatory compliance.
We are looking for an experienced people leader in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and at least two days a week at a CareFirst location based on business needs and work activities/deliverables that week.
ESSENTIAL FUNCTIONS: - Directs the day-to-day prioritization of work for a diverse staff of quality analysts, data engineers, data analysts, and quality improvement, and quality operations staff. Strategic oversight of vendor relationships supporting quality data or supporting audit functions. Ensures the implementation and ongoing execution of Quality Improvement initiatives improve performance, customer satisfaction & members quality of care.
- Lead enterprise HEDIS strategy, annual submission activities, and roadmap execution, including management of work plans, timelines, data acquisition strategies, vendor and provider data exchanges, audit readiness, accreditation support, and continuous quality improvement initiatives across all lines of business.
- Drive quality performance analytics and operational improvement efforts through trend analysis, year-over-year performance reviews, HEDIS and Stars score optimization, post-audit improvement planning, and the development of actionable reporting, scorecards, and measurement frameworks
- Maintains knowledge of current and future NCQA, NQF, CMS/Federal, State, regulatory and healthcare quality measurement requirements and accreditation standards. Actively participates in or chairs committees, sub-committees, enterprise & Industry workgroups as assigned to report, champion an advocate quality improvement, across populations.
- Directs the strategic and the day-to-day activities of the Department, including coaching and guiding individuals and teams in order to implement departmental, divisional, and organizational mission/goals. Recruits, retains and develops a high performing team. Evaluates performance of each team member, generates development plans and sets goals within the context of the corporate policies and procedures. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.
SUPERVISORY RESPONSIBILITY: This position manages people.
QUALIFICATIONS: Education Level: Bachelor's Degree in business administration, health policy, health services research, public health, economics, mathematics, computer science, or a related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 8 years experience in a healthcare, public health, health insurance, quality/process improvement or data management business environment
3 years management experience
Preferred Qualifications: - Training or certification in Quality or Process Improvement Methods
- Certified Professional in Healthcare Quality certification
- Clinical Qualification (RN/NP/PharmD)
- Data Analytics & Visualizations
- 5+ years of Quality Engine management, product or platform ownership
- Roadmap development and audit support
- Data acquisition of health care data through standard and non-standard data sources
- Vendor management
Knowledge, Skills and Abilities (KSAs) - Ability to perform qualitative and quantitative data analyses and create innovative strategies and work with colleagues to address findings.
- Ability to learn the technical aspects of collection and reporting of both administrative and clinical aspects of quality measures.
- Strong computer skills to include Microsoft Office.
- Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
- Ability to lead and direct analysts, clinicians and project/program managers.
- Public speaking and presentation skills.
- Deep understanding of the Customer Experience.
- Experience in Population Health Management concepts.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $142,560 - $264,627
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US Must be eligible to work in the U.S. without Sponsorship
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