Position Purpose
This position is responsible for managing all activities and functions of the Quality Improvement Program. Act as an advocate for, and support of the business by serving as a clinical quality champion through measuring and monitoring the quality and effectiveness of the care and service provided to our members. Lead and manage all aspects of clinical quality programs and projects and ensures compliance with government and state agencies.
Nature and Scope
This position is responsible for the implantation and documentation of Hometown Health's Quality Improvement Program in accordance with industry standards and regulatory requirements. This position makes business decisions based on the results of research and data analysis and has responsibility for decision making regarding the design, development, and implementation strategy of quality improvement projects, and initiatives. The Manager will form and leads cross functional teams to assist business units in integrating quality into their strategic and operational plans and also evaluates and prioritizes recommendations for quality improvement to senior management. . This position manages and is accountable for the Annual HEDIS audit and proactive annual reporting of key quality metrics. This position provides leadership and direction to all departments with Hometown Health in order that the process of quality improvement becomes the responsibility of all employees.
KNOWLEDGE, SKILLS AND ABILITIES:
1. Thorough knowledge of Quality Improvement implementation and management, HEDIS reporting, industry accreditation processes (TJC, URAC, NCQA) and quality requirements for Centers for Medicare & Medicaid Services (CMS).
2. Assures compliance with all State and Federal quality regulations, URAC Quality Standards, and NCQA Quality Standards
3. Provides direction setting and leadership, with accountability for quality programs, specialized audits, special reviews, projects, and initiatives.
4. Manages complex projects, people, and business priorities to achieve member satisfaction.
5. Collaborates with department leaders on initiatives to improve overall Star Ratings including clinical, Health Outcomes, CAHPS and pharmacy measures.
6. Develops and implements quality improvements activities for both Medicare and Commercial populations
7. Directs data collection for HEDIS and CMS Star Ratings; identifies opportunities for improvement based on results
8. Influences all stakeholders to support key quality projects/programs to ensure positive solutions that deliver results. Consults with internal/external stakeholders on solutions that impact clinical quality.
9. Develops education to staff, providers, and members regarding quality initiatives and member experience.
10. Oversees and coordinates incentive programs for members and providers to align with the Quality Improvement data driven strategy, in accordance with applicable regulations.
11. Develops and distributes educational information to members and providers in accordance with HEDIS outreach work plans.
12. Identifies potential resources and initiates collaboration with providers to improve member health outcomes and member experience.
13. Advanced problem resolution skills.
14. Leads coordination and management of Quality Improvement/Utilization Management (QI/UM) Committee and presents policy, programmatic, and work plan changes as appropriate.
15. Thorough knowledge of structure of health care delivery systems within managed care.
16. Excellent oral and written communication skills and ability to synthesize information from multiple sources into cohesive document or project plan.
17. Strict adherence to rules and regulations for maintenance of confidentiality of peer review and member medical information.
18. Advanced qualitative and quantitative analytical skills.
19. Ability to maintain effective working relationships with internal staff, physicians, other providers, staff, employers, regulatory agencies, and enrollees. Excellent communication skills and experience communicating at all levels within the organization.
20. Must be highly organized and be able to establish priorities and be proficient in use of word processing, spreadsheets and graphic applications.
21. Responsible for the planning, directing, and overseeing the operations of the quality department. Will maintain work systems, procedures, and policies that enable and encourage the optimum performance of the team.
This position does not provide patient care.
Disclaimer
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications
Requirements - Required and/or Preferred
Name
Description
Education:
Must have working-level knowledge of the English language, including reading, writing and speaking English.
Bachelor of Science in Nursing required.
Master's Degree in Nursing or other related Health Care field preferred.
Experience:
Minimum of five years' clinical and/or managed care experience required, including three years of experience in a managerial position. HEDIS or other regulatory (CMS, URAC, NCQA) quality audit experience preferred.
Demonstrated leadership ability to plan, organize, and execute multiple functional business objectives required.
Preference given to applicant with NCQA/URAC accreditation experience.
License(s):
Current State of Nevada Registered Nursing License required.
Certification(s):
CPHQ or ABQAURP Certification preferred
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
