Senior Manager of Quality Improvement and Analysis

Job Details

Job Location

Smithfield, RI - Smithfield, RI

Position Type

Full Time

Education Level

Bachelors Degree

Travel Percentage

Occasional

Job Shift

Daytime

Job Category

Management

Description

The Senior Manager of Quality Improvement and Analysis is Neighborhood's organizational lead for implementing all facets of the Healthcare Effectiveness Data and Information Set (HEDIS), Medicare Stars and related quality measurement and monitoring activities for all product lines.

In this role, the Senior Manager has oversight responsibility for assuring technical performance, achieving compliance with regulatory requirements, timelines, and standards, and providing ongoing analytical and clinical support and collaboration for the Plan's multiple cross-departmental quality improvement (QI) work groups.

The Senior Manager also has principal responsibility, with review and input from the Director, for multiple initiatives to gain access to and establish electronic exchange of clinical information from provider electronic medical records systems, clinical laboratory information management systems, and the State's immunization registry, working in collaboration with Neighborhood's Information Services and Business Operations Departments, external contractors, Accountable Entities, the Department of Health, and the Executive Office of Health and Human Services (EOHHS).

These clinical information sources include information critical for the Plan's risk adjustment and care management functions, as well as being essential for clinical quality measurement and oversight.

This position must continually strive to maximize Neighborhood's incentive award under the pay for performance programs such as Medicare Stars and Quality Withhold established by CMS and EOHHS, and actively target clinical quality benchmarks that drive Neighborhood's national health plan rating as determined by the National Association for Quality Assurance (NCQA).

Performance in these areas has a significant impact on the Plan's financial performance and on the Plan's reputation nationally and locally and with EOHHS, our providers, and our members.

The Senior Manager manages and leads the HEDIS Team consisting of analytic staff, managers, and clinical staff, ensuring they are extensively trained, and delegates work appropriately, assuring that the Team meets all deadlines and performance standards.

The Senior Manager also manages the HEDIS processing contractor and coordinates the process for the HEDIS audit with the NCQA-certified auditor and the HEDIS processing vendor.

Duties and Responsibilities :

Responsibilities include, but are not limited to, the following :

• Establishing and leading the operational work plans for HEDIS performance including all aspects of data collection operations, processes as well as for all quality-related requirements of the Accountable Entity Program.
• Day-to-day supervision of the HEDIS Team and delegation of specific responsibilities to both the analytical and the clinical teams within the Team including optimizing work efficiencies for the HEDIS team.
• Selection, oversight, and direction of the HEDIS processing vendor and the contractor serving as the Plan's NCQA-certified HEDIS auditor.
• Continuous strategizing and future planning to maximize HEDIS electronic data sources and processes, rate results and financial awards, such as Quality Withhold dollars and Medicare Stars.
• Continuous implementation of electronic health records integration, including developing and maintaining provider relationships.
• Manages, mentors, and trains the team and other health care professionals involved in HEDIS reporting. Provide all tools needed to do their job, keep them apprised of any software changes and data integrity issues and continually cross-trains the team to ensure business continuity of the HEDIS project.
• Provides analytical reports required for reporting to EOHHS under the Medicaid contract, the MMP program requirements, and the Accountable Entity requirements.
• With the Director, develops and monitors the annual budget for the HEDIS Team, contractors, and perdiem clinical nurse abstractors.
• Leads the identification of data that could potentially impact HEDIS rates, internal interventions and other company projects.
• Supports the identification of data integrity issues in the company including : managing the research, bringing all data issues to the attention of data governance, offering solutions for data issues and following up on progress.
• Continually seeks and implements methods to improve the accuracy and efficiency of HEDIS data collection operations including working closely with the HEDIS team to proactively resolve foreseen issues and develop and implement solutions.
• Manages and oversees the root cause analysis of all HEDIS rate information. Analyzes the company's HEDIS performance data to identify opportunities to improve services and outcomes for members and to monitor progress of improvement efforts.
• Produces and presents annual HEDIS results, results of special analyses of HEDIS data, and HEDIS processes and barriers to the quality and operations committees and other audiences identified by the Director.
• In coordination with the supervisory staff, explores and develops a coherent, collaborative, cross-measure strategy to support intervention efforts that involve strategic partnerships with providers, community health centers, state agencies, other health plans and other community organizations.
• Work closely with Quality Improvement, Analytics, Provider Contracting, Provider Relations, Case Management, Pharmacy, Behavioral Health and other areas within the company.
• Establishes and oversees contracts with the HEDIS software vendor and the HEDIS compliance auditor including developing, reviewing, and evaluating RFPs for potential new vendors.
• Coordinates with the National Committee for Quality Assurance (NCQA) on HEDIS specifications and submission requirements including keeping abreast of HEDIS public comments and changes publicized by NCQA.
• Assists the Director and Committee(s) in setting company-wide priorities / goals for HEDIS improvement.
• Proactively initiates, develops and maintains effective working relationships at all levels of the company keeping them informed of HEDIS rates, HEDIS impacts and data integrity issues.
• Performs other duties as assigned.
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company.

This position must exercise due diligence to prevent, detect and report unlawful and / or unethical conduct by fellow co-workers, professional affiliates and / or agents.

Qualifications

Qualifications

Required :

• Bachelors degree in a Health related area, healthcare informatics, data science or quantitative field
• Seven (7) or more years' of professional experience in health care, preferably in healthcare analytics
• Eight (8) to ten (10) years minimum experience managing, mentoring and training a team of health care data analysts and / or other healthcare professionals
• Five (5) to ten (10) years' hands-on experience leading and working with all aspects of HEDIS reporting and life cycles
• Extensive experience and strong knowledge of HEDIS and QRS (Exchange Product) technical specifications; HEDIS audit standards, quality data collection processes and standards, procedures including electronic clinical data systems
• Experience leading HEDIS regulatory audits
• Knowledge and experience in data collection, specifications, and key performance drivers of all Stars Measures
• Strong knowledge of claims, financial, membership, pharmacy, behavioral health, lab, and provider data
• Strong strategic thinking and planning to maximize all available data sources and results
• Strong ability to think critically, analytically, communicate complex data issues and suggest resolutions
• Demonstrated ability to work with and present results to high level internal and external entities, such as senior leaders, provider groups and state regulatory entities
• Demonstrated experience leading workgroups, designing quality improvement methods and other health care studies
• Strong experience with project management, including demonstrated ability to develop and implement detailed project plans and meet project timelines, team building, and program leadership
• Experience with RFP, contract review and vendor selection
• Demonstrated ability to work as part of a multi-disciplinary team
• Strong verbal and written communication skills
• Strong team building, coaching and leadership skills

Preferred :

• Master's degree in business administration, public health, economics, data science, informatics, or IT related field
• Experience using SAS, SQL or other statistical software
• Knowledge of Risk Adjustment data validation (RADV)
• Experience with new process implementation

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.