Manager Quality Health Integration

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.
  • Managing achievement and maintenance of NCQA accreditation.
  • Scheduling all information for surveys, conducting mock audits, Quality Management Committee facilitation, and providing consultation to business units and team leads regarding NCQA standard issues.
  • Supporting clinical integration by providing oversight and guidance to clinical staff and participating in internal and external care management work groups.
• Manages NCQA Health Plan and Utilization Management URAC Accreditation process, oversight of work plan, and develops three-year accreditation roadmap.
• Manages and oversees condition management department which may include, but is not limited to:
  • Supporting Aerial care management platform.
  • Managing program content and triggers
  • Collaborating with other population health departments to coordinate care.
• Manages and oversees clinical staff involved with medical appeals and reconsiderations.
• Oversight of the quality-of-care complaint process and peer review
• Performs human resource management duties including but not limited to hiring, training, and time and performance management. Consults with leader and Human Resources as required.
• Provide support and leadership to department staff while managing overall performance. Maximizes staff performance through regular team meetings, effective training, on-going 1:1 performance discussion, as well as formal performance review and meaningful development.
• Other duties as assigned.

Job Requirements:

• BS in nursing or related clinical field, required
• 5 years of experience in Health care industry
• 3 years of experience in leadership
• 3 years of managed care experience, including experience in program development and knowledge of the quality process and QI techniques preferred
• 5 years HEDIS, Stars and/or NCQA required
• URAC Accreditation experience a plus
• Prior experience managing or leading a NCQA Accreditation survey required.

 We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.