Mgr, Quality Management

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.

About the Role

This position is responsible for leading all aspects of Quality Management Clinical Operations & Audit and Quality Management Performance Reporting, including HEDIS and STARS performance for Horizon Government Programs.

Responsibilities

• Directs staff to support quality improvement initiatives specifically related to Quality Audit, HEDIS, Stars, and NQCA Accreditation.
• Develops policies and procedures to support quality improvement initiatives and processes.
• Participates in special projects as assigned by the Director.
• Represents the department with internal customers and Sr. Leadership in the event of Director's absence.
• Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.
• Provides leadership and utilizes professional and communication skills to direct and motivate staff to ensure high quality outcomes.
• Represents the Plan with external customers, providers, and external agencies and represents the unit on corporate issues and/or in the event of Director's absence.
• Manages, directs, and develops staff by providing feedback and coaching. Administers performance and salary reviews for staff. Ensures staff meets all regulatory requirements and utilizes best practice methodology.

QM Performance Reporting

• Develops annual HEDIS chart review training and administers inter-rater reliability.
• Develops HEDIS provider chase strategy to meet Horizon's goals.
• Oversees Quality Management compliance of HEDIS chart reviews and overreads.
• Responsible for development and implementation of HEDIS Roadmap.
• Develops and implements initiatives to improve HEDIS and Stars performance.
• Manages and oversees Horizon's Pay for Performance program.
• Conducts provider onsite visits to promote and support Pay for Performance program.
• Manages relationships and supports external providers to improve HEDIS and Stars performance.
• Collaborates with Value Based Programs and Provider Contracting and Services to manage provider quality performance.

QM Clinical Operations

• Develops and implements strategies for quality improvement and initiatives.
• Responsible for assuring timely correction of deficiencies, identification of problem providers, and promptly reports difficulties or lack of cooperation to the Director of Quality Management.
• Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.
• Works with Utilization Management to develop related policies and procedures.

Requirements

• Requires a Bachelor's degree from an accredited college or university.
• Requires five (5) years of experience in a healthcare setting: health plan, hospital, physician practice, or managed care organization.
• Requires a minimum of five (5) years of quality management experience.
• Requires a minimum of five (5) years of management experience.
• Requires project management experience.
• Master's Degree preferred.
• Prefers experience in continuous quality improvement and/or quality management.

Qualifications

• Requires knowledge of HEDIS, CAHPS, and Medicare Stars.
• Requires working knowledge of NCQA accreditation standards.
• Requires thorough knowledge of managed care products.
• Requires knowledge of MCO and Horizon BCBSNJ products, services, and programs.
• Requires the ability to think analytically and to use logic in solving problems.
• Must be proficient in the use of personal computers and supporting software in a Windows-based environment, including MS Office products (Word, Excel, PowerPoint & Outlook). Should be knowledgeable in the use of intranet and internet applications.

Skills and Abilities

• Requires excellent verbal and communication skills.
• Requires strong project management skills.
• Requires strong organizational skills.
• Requires strong problem-solving and decision-making skills.
• Requires good analytical skills and the ability to interpret data to improve quality performance.
• Requires strong relationship-building skills to work collaboratively across departments/divisions.

Travel

Must be willing to come into the Newark, NJ office several times per year.

Pay

Salary Range: $109,600 - $149,625. This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision).
• Retirement Plans.
• Generous PTO.
• Incentive Plans.
• Wellness Programs.
• Paid Volunteer Time Off.
• Tuition Reimbursement.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.