In collaboration with Quality Director, support the development and implementation of quality improvement interventions and audits, as well as assist in resolving deficiencies that impact plan compliance with regulatory and accreditation standards. The Quality Manager helps drive key quality improvement projects, which requires the ability to work effectively in a matrix environment in order to receive needed data that reflects the overall effectiveness of the health plan. Provides leadership for complex analytics and reporting in support of the annual HEDIS submission, Medicare Star program, QRS submission, NCQA/URAC accreditation, and regulatory and contractual compliance projects.
In collaboration with Quality Director, develop and implement the quality management program description, evaluation (CQMP) and work plan. Identifies opportunities for clinical performance improvement and develops quality improvement initiatives related to clinical performance and other quality activities
Maintains current knowledge of the health plan's policy and procedures and ensures program compliance to the governing regulatory body, NCQA standards, and Participates in oversight activities as required by regulatory and accrediting bodies.
Acts as a knowledge expert for continuous quality improvement activities, educating staff of other functional areas regarding the QI process and accreditation requirements (NCQA).
Responsible for planning, execution, and evaluation of large and complex program initiatives to improve quality performance for all Lines of Businesses.
Responsible for concurrent and/or retrospective review, data abstraction, analysis, identification of critical issues, process improvement support, required education and assisting with measurement of performance metrics for different business units in the health plan
Communicates programs, interventions, and results to external entities in accordance with applicable program objectives, policies, and
Determines the resources and participants needed to achieve quality team goals.
Delegates tasks and responsibilities to manage dependencies and critical path resulting in program activities completed on time.
Demonstrates the ability to work with and influence team members functioning in a matrix environment.
Demonstrates thought leadership, excellent project management skills, knowledge and experience with program evaluation and consulting skills.
Provide training and guidance to the team with the interpretation of raw data, statistical results or otherwise compiled information, identify follow-up action items and prepare or assist in the preparation of written reports and/or oral presentation of findings to Director, Manager and/or other leaders.
Acts as a liaison for the health plan with outside entities, including physicians, hospitals, health care vendors, social service agencies, member advocates and regulatory agencies, among others.
Participates in interdisciplinary committees to maintain understanding and participation in projects and policies related to compliance with quality standards and initiatives.
Develop, implement and monitor the Stars Program and Plan through a complete understanding of the CMS technical specifications.
Manage and engage staff around interventions that improve HEDIS, CAHPS, and HOS for the highest level of quality in clinical care and service.
Integrate the stars program and plan to excel NCQA accreditation ratings.
Manages the contractual relationship with NCQA-certified HEDIS vendor and HEDIS auditor.
Manages program expectations, frequency, and content of status reports to track annual HEDIS milestones and deliverables and develops best practices and tools for performance measure reporting and management.
Responsible for managing data abstraction and medical record review processes; and identification of critical issues and process improvements to optimize measure results.
Train the team members to build and develop collaborative relationships vital to the success of HEDIS and STARS outreach programs.
Coordinates and monitors the activities and results of surveys conducted for various purposes, including the CMS, required Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Qualified Health Plan (QHP) survey.
Bachelor's Degree in a clinical area or Master's Degree in the related health field (i.e. MPH or MPA).
Minimum of three years' experience in a clinical/health care environment with the related degree program.
License/Certification: Lean Six Sigma Green Belt preferred.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.