Job Description

Summary of Job

Identify, develop, execute, evaluate and provide oversight of quality and process improvement projects required to support public health, HEDIS®, QARR, NCQA and other regulatory quality measures for our network providers that EmblemHealth members receive across the enterprise. Develop and monitor Quality Improvement metrics in collaboration with department leadership to ensure that gains are maintained and corrective actions are taken as necessary to ensure performance improvement and to support compliance with HEDIS, QARR, and Star processes across all regions where we have membership. Drive and monitor clinical performance with vendor activities to support continued improvement in the quality data set. Collaborate with the leadership of Provider Network and Product, Analysts, IT and other cross functional teams to align strategies and quality improvement priorities in contracting, vendor relationships, sales and product development, and procurement. Manage a team of associates to achieve optimized quality and stars ratings from internal stakeholders and network providers.

Responsibilities

• Support Quality improvement processes for our network providers across all regions where we have members.

• Collaborate cross-functionally and with all vendors to define quality and process improvement projects that support corporate initiatives and have a reasonable chance of success with measurable and timely results.

• Review and analyze quality-related data to design, develop, monitor, and evaluate clinical and administrative service studies to support quality improvement activities and programs.

• Prepare reports, abstracts, and presentations based on the analysis of process/outcome measures of various behavioral health clinical studies and present formal study findings to various committees/groups within the organization as well as at professional conferences.

• Manage the Provider Incentive Program (PIP) across the enterprise to drive improved quality performance of network providers. Carry out project plans and roadmaps for provider collaboratives that define the path to specific actions resulting in improved quality performance for Medicare, Medicaid and the Exchange business. Performance improvement includes HEDIS, CAHPS and HOS measures that will improve plan Quality scores.

• Define and implement the enterprise strategies to deliver quality excellence, including measurement of each strategy to further refine and improve results.

• Manage engagement and Quality education tools for providers and vendors and report on their use and effectiveness.

• Develop measurement tools for data collection, metrics to assess the effectiveness of process revisions, and control tools for use in monitoring and sustaining project results.

• Ensure that corrective action plans are instituted accordingly across the company. Apply appropriate statistical procedures for the analysis of quantitative and qualitative data and evaluation of clinical and administrative service improvement activities.

• Actively participate in selected quality improvement committees, subcommittees and workgroups to support process improvement activities. Review and update operational processes relating to quality management activities. Define and document newly established processes.

• Support preparation, organization and follow-up in acquiring and maintaining NCQA accreditation and compliance with local, state and federal regulatory authorities, includes support of the health plan’s HEDIS, QARR, and Star processes

Qualifications

• Bachelor’s Degree in a health services field (Required); Advanced degree (Preferred)

• Six Sigma Green or Black Belt (Preferred)

• 5 – 8+ years’ experience in the health care field, preferably in managed care experience (Required)

• Ability to work with staff in several locations where the company has offices, necessitating site visits (Required)

• Staff/process management experience (Preferred)

• Proficient in MS Office - Word, PowerPoint, Excel, Outlook, Teams, SharePoint, etc. (Required)

• Proficient in MS Access (Preferred)

• Experience with and proficient in data analysis (Required)

• Strong working knowledge of relational database and statistical analyses (Preferred)

• Strong working knowledge of QI process improvement methodology strategies - PDSA and DMAIC (Required)

• Familiarity with the HEDIS®, QARR, CAHPS and HOS requirements (Required)

• Must possess analytical skills to collect, organize and present data in a clear and concise manner (Required)

• Ability to assess all work and prioritize as necessary to meet reporting timeframes and deadlines (Required)

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