What are the responsibilities and job description for the Manager Quality Health Integration position at Network Health?
Description
Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Manager of Quality Health Integration who will be responsible for managing activities for NCQA Health Plan and URAC accreditation, CMS Stars Programs, and the clinical components of the Quality Health Integration Program including HEDIS, clinical integration, clinical quality interventions and / or other quality audit related activities. This individual is responsible for the operational oversight of the condition management department and the clinical staff performing medical appeals and reconsiderations, quality of care concerns and the Peer Review process. In addition, they make decisions that impact clinical department goals and operations.
This individual will develop, implement, and evaluate current condition management and quality management processes including operational statistics, staff-related service standards and member-focused process improvement initiatives to identify opportunities for program updates. In addition, they will assist in the development of clinical departmental and interdisciplinary Quality Health Integration Teams to establish, measure, and report Quality Health Integration (QHI) and performance priorities collaboratively with the director; and co-lead quality improvement workgroups and committees in identifying, planning, and executing quality improvement, Medical Loss Ratio (MLR), and Peer Review activities.
Job Responsibilities :
- Provides oversight in the planning, implementation and coordination of CMS and NCQA audits to ensure high-quality, cost-effective care is rendered by employees and the organization.
- Oversight, development and participation in internal and external quality review activities and interventions.
- Manages and oversees quality assurance staff and activities, which may include, but is not limited to :
Supporting the HEDIS and CMS Stars staff with the production of HEDIS reports, Medical Record Review and the identification of interventions to improve outcome measures.
Supporting Aerial care management platform.
Job Requirements :
We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.
