The Quality Improvement Manager is responsible and accountable for leading key components of the Plan’s Quality Assessment and Performance Improvement (QAPI) Program including consultation regarding clinical and operational quality improvement initiatives. The Quality Improvement Manager assigned to the New Hampshire contract serves as the NH Quality Improvement Director. The Quality Improvement Manager is responsible and accountable for clinical quality improvement initiatives which comply with contractual obligations, regulatory requirements and accreditation standards. As applicable, provides clinical high-level support for process and operational improvements related to clinical initiatives within the Office of Clinical Affairs. He/she also oversees quality improvement initiatives by providing both high-level and individual program management involving significant cross-functional interface complexity, risk and cost. Has the ability to evaluate project/program options and to make recommendations that meet overall business objectives. Works with leaders at all levels throughout the company and with the State to ensure the success of the program and compliance with all contractual obligations.
Serves as Quality Management subject matter expert to the medical and/or behavioral health (BH) programs and executes new strategic quality initiatives designed to support corporate goals including NCQA accreditation.
Provides day-to-day oversight of quality improvement needs in all products and all EQRO and quality requirements.
Chairs the workgroups and committees which oversee progress with all corporate, regulatory, and contractual quality improvement initiatives.
Ensures the Plan meets contractual (e.g. EOHHS, DHHS, EQRO, NCQA and other regulatory/ accreditation bodies) requirements for medical and/or BH related quality improvement projects:
Develops detailed project plans and timelines for performance improvement project implementations and reviews.
Facilitates large multidisciplinary project teams and smaller sub-teams so that each performance improvement project has appropriate outcome metrics, measures of success, and interventions that are specific to meet expectations.
Generate supporting documentation for new project proposals, including internal and external reports.
Performs annual medical record auditing to support various quality improvement contractual requirements.
Works with clinical/quality, data analytics team and others as needed, to ensure that data needs are identified and incorporated into the process including performing data analysis as needed.
Serves as the liaison with vendors, as appropriate; to incorporate vendor data into assigned regulatory and/or EQRO reports.
Collaborates with Directors and Managers of BH and Medical Care Management regarding initiatives.
Prepares timely submissions for assigned projects, and responds to regulatory inquiries regarding submissions.
Represents the Plan at state Quality Management meetings as needed. Solicits internal input in preparation for external meetings.
Responsible for tracking feedback and clinical corrections from providers on condition specific reports and mailings.
As appropriate, provides clinical support for development, evaluation and revisions to the Plan’s Clinical Registry.
As appropriate, reviews, investigates and responds to clinical member grievances.
As appropriate, responsible for review, investigation, tracking, trending and annual reporting of medical adverse events/serious reportable events/provider preventable conditions including follow up and corrective actions in conjunction with the Plan medical directors. Makes recommendations to the Chief Medical Officer for non-payment of related claims as appropriate.
Coordinates the submission of all regulatory and quality related projects so that they are submitted on time and complete.
Develops and implements a process to utilize internal and external data sources, including quarterly reports, monthly management reports and population studies to identify interventions and potential topics for performance improvement projects initiatives.
Manages day-to-day quality processes including document preparation, literature reviews, and web–search requiring a high degree of independent decision-making.
Works with the medical directors, senior leadership and physicians to achieve corporate medical initiatives.
Regular and reliable attendance is an essential function of the position.
Other duties as assigned.
Bachelor’s Degree in nursing, health administration or related field required.
Master’s Degree in Social Work, Behavioral Health, Public Health or related field preferred.
5+ years progressive experience in health care / managed care.
Registered nurse with active license preferred.
In depth knowledge of and experience with clinical quality management and related business goals and practices within related areas preferred.
Experience with Medicaid/Medicare recipients and community services preferred.
Prior experience with NCQA preferred.
Experience in project development and / or health policy preferred.
Lean Six Sigma or CPHQ training preferred.
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Internal Number: 292891
About BMC HealthNet Plan
BMC HealthNet Plan is a non-profit managed care organizations committed to providing the highest quality healthcare coverage to underserved populations. In Massachusetts, BMC HealthNet Plan is the business name for Boston Medical Center Health Plan, Inc.; outside Massachusetts, Well Sense Health Plan is the business name.