Medicare Stars Manager

KHS reasonably expects to pay starting compensation for the position of Medicare Stars Manager in the range of $117,487 - 149,796 salary.

"On-Site Position"

About us

Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.

About the role

Under general direction of the Director of Delegation and Oversight, the Medicare Stars Manager is responsible for the planning, design, and operational management of the Medicare Stars Program for the Dual Special Needs Plan (D-SNP) line of business. This position will ensure that the organization performs program planning and design in support of development and implementation of the Medicare Stars Program and performs on-going operational program management, data analysis, and reporting to ensure regulatory compliance.  The Medicare Stars manager will work collaboratively with delegated entities, KHS departments, and external stakeholders to maximize Star ratings and HEDIS, and performs other duties as assigned.

Essential Duties and Responsibilities

Performs program planning and design in support of development and implementation of the Medicare Stars Program and performs on-going operational program management, with duties including but not limited to:

• Developing the Medicare Stars Program strategic objectives in alignment with the Centers for Medicare and Medicaid Services (CMS) Stars Rating System
• Developing and implementing a comprehensive Stars Program strategy in alignment with the organization’s goals and objectives. Monitor performance metrics and identify areas for improvement
• Overseeing the development, implementation, and management of Stars Program initiatives across all departments
• Monitoring and evaluating that impact of Stars Program initiatives and progress against program goals and objectives, identifying issues, and developing solutions
• Developing and implementing quality improvement initiatives to address gaps in Stars performance and improve performance in critical areas
• Monitoring, tracking, and communicating Stars-related Key Performance Indicator outcomes to improve the effectiveness of the Stars Program
• Ensuring compliance with all CMS regulations and guidelines related to the Stars Rating System, quality, and reporting
• Staying updated on regulatory changes and implement necessary changes
• Preparing and filing reports on measures included in the CMS Stars Rating System and maintaining related records
• Working with the Compliance Department to ensure that Stars Program activities comply with rules related to Medicare and the Dual Eligible Special Needs Plans (D-SNP)
• Developing and maintaining documentation to support compliance efforts and conducting regular audits and reviews to identify and address compliance risks
• Communicating potential compliance risks to the Compliance Department and Director of Delegation and Oversight
• Supporting the development of auditing and monitoring activities to ensure complete and accurate data sources that comply with CMS Stars measure specifications
• Ensuring readiness for CMS D-SNP Stars audits, gathering information and materials in support of audit preparation, assisting with development of audit responses, coordinating responses to audit findings, and implementing corrective actions and monitoring their effectiveness
• Representing the Stars Program to external stakeholders, including making presentations and discussing incentives with primary care providers
• Participating in the development of policies and procedures related to the Stars Program
• Participating in the evaluation of program goals to ensure alignment with departmental and organization-wide goals
• Supporting the Director of Delegation and Oversight in the preparation of required reports and submissions.
• Performs data analysis and reporting in support of Stars Program activities, with duties including but not limited to:
• Performing data analysis to develop strategies to meet short- and long-term operational and financial plans for the Medicare D-SNP line of business
• Analyzing data to identify trends, root causes of performance issues, and opportunities for improvement
• Reviewing claims and encounter data to identify opportunities for intervention and ensure alignment with Stars ratings
• Reviewing reports, identifying issues, and collaborating with appropriate internal stakeholders to address issues
• Evaluating the need for multiple interventions and the cross-functional impact of issues identified through data analysis
• Preparing and presenting regular reports on performance and progress of quality performance, Stars Program, and improvement initiatives, for senior management
• Providing insights and recommendations resulting from data analysis to KHS leadership
• Gathering and providing data to support regulatory reporting related to the CMS Stars Rating System
• Working with Information Technology Services to create reporting requirements
  
  

Works collaboratively with all KHS departments and external stakeholders to maximize Stars ratings, with duties including but not limited to:

• Acting as a subject matter expert to all levels of staff and as primary point of contact for overall coordination of the Stars Program
• Interpreting regulations that govern the CMS D-SNP Stars Rating System and advising regarding the application of operational strategies and tactics to maximize Stars Rating System outcomes
• Collaborating with KHS teams, including Quality Improvement and Population Health, Provider Network Management, Pharmacy, and Member Services, to promote the development and implementation of operational systems and initiatives aligned with Stars Rating System goals and CMS requirements
• Advising and participating in multi-disciplinary teams to develop and implement strategies and processes to maximize HEDIS/Stars ratings
• Leading and participating in cross-functional project teams to identify opportunities for improved clinical outcomes
• Working with Provider Network Management to make any changes needed in order to meet contract performance criteria
• Working with departments across the organization to ensure compliance with CMS requirements, improve quality metrics, and enhance member satisfaction
• Providing strategic guidance to stakeholders across the organization to support process improvement and execution to maximize Stars ratings
• Staying informed about prospective changes to the Stars Rating System and communicating changes in requirements to internal stakeholders in a timely manner
• Developing and facilitating training related to Stars Rating System requirements
• Performs other duties as assigned
  
  

Employment Standards

Education and experience:

• Bachelor’s degree in Business, Healthcare Administration, Public Policy, or equivalent;
• Six (6) years of experience in a managed care setting which included a minimum of five (5) years of experience in Quality Improvement program/project management and a minimum of two (2) years of experience working with the CMS D-SNP Stars Rating System
• A Master’s degree may substitute for two (2) years of the general managed care experience); or an equivalent combination of education and
  experience may be qualifying
  
  

Knowledge of: 

• Thorough knowledge of the principles and practices of quality improvement in a managed care environment
• Working knowledge of the Medicare Program and related regulations
• Working knowledge of HEDIS/Stars measures and the audit process
• Working knowledge of State and Federal regulatory requirements, particularly related to QI/QP activities
• Working knowledge of the CMS D-SNP Stars Rating System
• Working knowledge of the principles and practices of strategic planning
• Working knowledge of the principles and practices of program development, implementation, management, and evaluation
• Working knowledge of the principles and practices of project management
• Working knowledge of research, analysis, and reporting methods
• Working knowledge of and proficiency with Windows based PC systems and Microsoft Word, Excel (including pivot tables), Outlook, PowerPoint
• Some knowledge of complex practices, issues, and theoretical principles related to Medicare Advantage or D-SNP, including the market and regulatory environment
• Some knowledge of State and Federal legislative processes
  
  

Ability to:  Communicate Stars Rating System requirements and their impacts on KHS operational systems; develop and implement strategic plans; work effectively with cross-functional teams and build strong relationships with stakeholders; act as a technical resource and explain complex laws, regulations, processes, and programs related to areas of responsibility; demonstrate strong analytical skills, accurately collect, manage and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk; identify, discuss, evaluate, and resolve complex and unusual problems in a timely manner; lead or assist with the development and implementation of programs, projects, systems, policies, and procedures; manage multiple projects simultaneously, organize work, and achieve goals and timelines; identify new processes and systems to improve productivity and results; manage and evaluate the work of contracted vendors and consultants; understand contractual language and its impact on vendor obligations and performance; foster effective working relationships, influence others, negotiate and persuade others, and build consensus with individuals at all levels in the organization and with external stakeholders; demonstrate a collaborative working style, build rapport, and effectively manage internal and external business relationships; provide leadership, facilitate meetings, and influence and motivate project team members and peers to achieve program goals and objectives; make presentations and adjust communication style in order to facilitate collaboration and understanding; prepare written and oral reports, correspondence, and other program documents; develop recordkeeping systems and maintain organized and accurate records; develop training materials, in conjunction with Learning and Development staff, and conduct training; work independently, manage assigned workload, make decisions related to areas of functional responsibility, and recognize issues requiring escalation.

Other:  Required travel up to 40%. Possession of valid California Driver’s License and proof of valid State required auto liability insurance.