The VP, Performance Improvement creates and drives a common framework for continuous improvement, including the development of core principles, critical processes, and key performance indicators. Additionally, this position will utilize these principles, process, and indicators to identify, plan, and support execution of targeted improvement initiatives. Builds action plans, tools, and processes to identify improvement opportunities. Leads collaborative exploration to increase ability to meet the needs of customers. Partners closely with senior leadership to understand the business and the challenges and must be detail-oriented and metrics-driven. Creates and drives workflows resulting in quality and financial improvements across the business enterprise.
- Develops and owns Performance Improvement Workplan. Key areas of performance improvement may include utilization reduction, medical or pharmacy unit cost reduction, HEDIS/Stars results, and staff productivity.
- Leads productivity improvement efforts for Population health activities.
- Manages Project Management Office dedicated to new initiatives, partnerships, and other activities.
- Manages risk sharing deals with providers either as sub-capitation or payment/performance alignment.
- Develops operational management reporting to support state, regional and care team management. Support of feedback loops to measure consistency and effectiveness of interventions.
- Strives to monitor and communicate State and Federal regulatory activities while working to promote and ensure Risk Adjustment activities that are compliant with all applicable laws, regulations, rules, and policies. As directed, assists in communicating with external regulatory bodies relating to clinical quality performance and improvement projects.
- Assists with the bi-annual NCQA accreditation process. Ensures compliance with standards, manages the audit process, and is the executive owner of the NCQA overall rating.
- Assists with the oversight and development of programs to meet business objectives, CMS regulations and quality standards for Medicare Advantage Risk Adjustment and Commercial Risk Adjustment lines of business working with the VP Compliance
- Manages the development of client audit processes to meet and maintain regulatory and operational requirements, including reporting a detailed analysis of any issues, making recommendations, and measuring the outcome.
- Serves as the leader for driving the strategy to achieve high level performance in all quality ratings programs such as Medicare Star, Medicaid quality and NCQA ratings. This position is ultimately responsible for the company’s annual Star rating which is a critical factor in the company’s financial success.
- Maintains an in depth understanding of all quality measurements, including HEDIS, Supports the HEDIS collection process with focus on removal of barriers to success.
- Accountable for the member experience related to Performance Improvement activities, including oversight of member materials that will drive member engagement.
- Master’s degree in Business or Healthcare
- 3-5 years of relevant work experience
- Ability to handle multiple tasks and meeting deadlines in a fast-paced environment
- Proficient in Microsoft Office Products including, Excel, Access, Word, PowerPoint
- Thorough understanding of Medicare Advantage Plans and Commercial (QHP) plans including compliance, audits, chart review, and reporting requirements
- Deep understanding of value-based care
- Ability to review and analyze data file submissions
- Ability to read, analyze, and interpret professional/ legal/ medical documents, policy and procedures, government regulations, and legislative documents