Clinical Quality Program Manager III

About the role

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Responsibilities

• Identify, implement, and guide projects relating to quality excellence in CMS Five-Star Rating System and Marketplace Exchange Quality Rating Systems (QRS).
• Strategize quality improvement programs and ongoing management using a data-driven focus that sets priorities for improvements aligned with ongoing strategic initiatives.
• Collaborate with QI/QPM, HIM analytics support, Risk Adjustment, other plan operations business units, and network providers to strategize and promote success in achieving enterprise wide quality goals and initiatives.
• Develop and track work plans; identify and implement short- and long-term interventions and programs that support goals to improve quality program ratings; provide oversight in deployment and evaluate effectiveness.
• Track, manage, and report project progress and outcomes; manage vendor contracts.
• Facilitate collaboration with internal and external stakeholders to ensure full integration of initiatives throughout the organization.
• Serve as a subject matter expert on Clinical Quality programs, interventions, and quality metrics related to Medicare Stars or Covered California QRS programs, including CAHPS, HOS, HEDIS, Medication Adherence, Plan Operations, Pharmacy, Administrative/Regulatory domains.
• Act as a resource and mentor for other staff.
• Develop and maintain clinical quality work plans; convene committees and workgroups; lead Core Teams by leveraging technology and tools to streamline processes, enhance collaboration and synergy, promote data sharing, and improve transparency across clinical and operational areas.
• Drive collaboration, education, training, and maintain working relationships across Core Teams with multiple departments including QI, Pharmacy, Care Management, Utilization Management, Risk Adjustment, Products, Customer Solution Center, reporting and Analytics, Appeals and Grievances, and the provider network.
• Manage and maintain SharePoint sites to ensure regulatory guidance is available to stakeholders and enterprise-wide activities are documented and shared among accountable entities and network providers.
• Coordinate workgroup meetings; send reminders, format agendas, minutes and handouts; manage the team SharePoint site; follow up on action items.
• Work closely with QI, Health Services, Reporting/Analytics, vendors, and the provider network on shared quality initiatives, data sharing and analyses.
• Monitor and track enterprise-wide quality interventions and analytical strategies that elevate quality of care and enhance satisfaction for members.
• Lead quality reporting and analytical strategies to enable accountable entities and stakeholders to drive quality ratings improvement for CAHPS, HOS, HEDIS, Medication Adherence, Plan Operations, Pharmacy, Administrative/Regulatory, or other QRS-specific metrics.
• Assist with identifying measures needing performance improvement; evaluate data; coordinate discussion/workgroups to develop strategy and work plans.
• Research and implement best practices to improve population health and quality of life and evaluate impact.
• Apply subject expertise to evaluate business operations and processes; identify areas where technical solutions would improve performance.
• Consult across business operations, provide mentorship, and contribute specialized knowledge.
• Ensure project/program deliverables meet department, organizational, and legislative policies, standards, and best practices.
• Provide training, recommend process improvements, and mentor junior-level staff and interns as needed.

Requirements

• Bachelor’s degree; in lieu of degree, equivalent education and/or experience may be considered.
• At least 5 years of experience in a health plan specializing in healthcare quality, informatics, QI initiatives and analytics.
• Experience implementing initiatives to improve quality ratings and managing projects and programs end to end.

Qualifications

• Preferred: Master’s degree in Public Health or related field.
• Preferred: Experience in a health plan specializing in CAHPS, HOS, HEDIS, Medication Adherence, Plan Operations, Pharmacy, Administrative/Regulatory, or other QRS-specific metrics.
• Preferred: Experience implementing initiatives to improve quality ratings and managing projects and programs end to end for the above-specified metric sets.

Skills

• Thorough knowledge of health plan quality ratings including Medicare Stars and/or Marketplace Exchange Quality Rating Systems (QRS).
• Demonstrated analysis skills; aptitude for accuracy and attention to detail.
• Proficient in Microsoft Office tools.
• Ability to present data and analysis in a meaningful way, tailoring the message to the audience.
• Excellent verbal, written, and presentation skills.
• Demonstrated critical thinking, problem-solving, and process improvement skills.
• Independent judgment and action to facilitate change as needed.
• Knowledge of managed care industry standard performance assessment methods.
• Ability to work in a team environment with good communication skills, supportive attitude, and mentorship ability.
• Demonstrated ability to work collaboratively, seek solutions proactively, and apply critical thinking to evaluate priorities and solutions.

Licenses/Certifications

• Required: Appropriate licenses/certifications as required by role.

Pay

Salary Range: $102,183.00 (Min.) – $132,838.00 (Mid.) – $163,492.00 (Max.)

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)