Job Description
Job Description
Under the direction of the VP, Medical Economics & Program Evaluation and the VP, Quality Improvement, is responsible for coordinating all activities related to HEDIS analytics and reporting, and Quality & Performance Impovement initiatives. The Sr. Manager, HEDIS & Quality Improvement will directly supervise the Quality Data Analysts, Quality & Performance Improvement Nurse Coordinators and Quality Medical Record Abstractors. The Sr. Manager, HEDIS & Quality Improvement will lead the development and refinement of Quality Measure reporting, including VBC and Interal Dashboard reporting, as well as other inititaive based reporting. The Sr. Manager, HEDIS & Quality Improvement will also develop, organize, prioritize, and execute specific data retrieval and medical record abstraction initiatives to support quality metrics related to HEDIS gap closures, Medicare Stars measures, NCQA, BMS, CMS, and other key quality metrics throughout the year, and will assist with implementing and monitoring plan-wide Quality Improvement & Quality Management initiatives, improvement projects, and compliance related to NCQA / External Quality Review Organization activities, accreditation, HIPAA Privacy Standards, Medicare Standards, BMS Standards and NCQA Standards.
Required :
- College BS degree in quantitative, communications or health-related field; statistical knowledge preferred.
- Prior HEDIS oversight experience (minimum 3 years).
- Prior Managed Care experience (minimum 5 years).
- Supervisory and project management experience (minimum 3 years).
- Effective written and verbal communication skills.
- Computer application skills including Excel, Word, Power BI, Outlook, etc..
- Ability to plan, execute and complete long-term projects.
- Experience with automated information systems and computer generated data.
- Strong analytic and critical thinking skills.
- Relevant experience in Quality Improvement PDSA Cycles.
- Ability to work independently as well as part of a team in a fast paced environment.
Desired :
Medical coding experience or certified coder.Medical claims experience or adequate understanding.Relevant experience in HEDIS, NCQA Health Plan Accreditation, Medicare Star Ratings, CMS and BMS regulations.Responsibilities :
Oversee the development and refinement of Quality Measure (HEDIS, Stars and other metrics) Dashboard reporting to support internal and Value Based Contracting initiatives.Coordinate and oversee the yearly HEDIS reporting and Auditing processes; including contracting, roadmap completion, measure production, data analysis, report production, and NCQA reporting elements.Oversee the development and prioritization of initiative based Quality Measure reporting to support internal and external teams.Direct oversight of the HEDIS Data Analyst, Quality & Performance Improvement, and Quality Medical Record Abstractor teams; including quality assurance, productivity monitoring, time sheet approval, scheduling, vacation approval and performance evaluations.Develop workflows and document processes into THP Policy & Procedure.Review and provide feedback on documents such as newsletter articles, mailings and educational materials that are intended to directly impact HEDIS performance and results.Oversee HEDIS data feeds to and from THP's certified HEDIS vendor and auditor, and other parties if / as needed.Prepare, track and trend monthly HEDIS reports via Dashboarding.Manage, educate, and monitor staff activities related to data retrieval and medical record abstraction to support various quality metrics including but not limited to HEDIS and Medicare Stars.Collaborate with internal departments, including Clinical Services, Pharmacy Services, and Medicare, Medicaid, and Commercial Operations teams to identify quality measure / metric improvement opportunities, medical record abstraction initiatives and quality improvement projects.Responsible for yearly and ongoing HEDIS quality metric training to Quality Improvement staff and various departments throughout The Health Plan as needed.Develop and update of yearly employee HEDIS manual and other training materials as needed.Serve as the Quality Improvement subject matter expert in HEDIS technical specifications.Support staff in performing moderately complex medical record retrieval and abstraction through various software applications to support HEDIS measures, including supplemental HEDIS data, and other quality improvement initiatives and auditing projects.Assure staff medical record chart abstractions are completed timely and in accordance with HEDIS technical specifications and guidelines and other applicable regulations and policies through over-read process.Participate in internal and external stakeholder meetings to support medical record abstraction initiatives, HEDIS gap closures, and other quality improvement projects.Coordinate and support multiple quality improvement projects, initiatives, and audits.Monitor targeted key performance indicators for specific quality measures, assisting with administering and monitoring of quality improvement projects and activities related to enhancing organizational compliance with NCQA, CMS, BMS, Qlarant, and HEDIS / Star measures.Collaborate with internal departments, delegated entities, and vendors to enhance compliance with regulatory guidelines and improve key performance indicators.Assist in development of training materials to employees, providers and members on key performance indicators and quality improvement initiatives related to NCQA, HEDIS, Medicare Stars, CMS, and BMS.Consistently demonstrates professionalism and compliance with state and federal regulations, such as HIPAA.
