Quality Manager

About the role

This position is responsible for managing all activities and functions of the Quality Improvement Program. Act as an advocate for, and support of the business by serving as a clinical quality champion through measuring and monitoring the quality and effectiveness of the care and service provided to our members. Lead and manage all aspects of clinical quality programs and projects and ensures compliance with government and state agencies.

Responsibilities

• Implements and documents Hometown Health’s Quality Improvement Program in accordance with industry standards and regulatory requirements.
• Makes business decisions based on the results of research and data analysis.
• Designs, develops, and implements strategy for quality improvement projects and initiatives.
• Form and lead cross-functional teams to assist business units in integrating quality into their strategic and operational plans.
• Evaluates and prioritizes recommendations for quality improvement to senior management.
• Manages and is accountable for the Annual HEDIS audit and proactive annual reporting of key quality metrics.
• Provides leadership and direction to all departments with Hometown Health in order that the process of quality improvement becomes the responsibility of all employees.
• Develops and implements quality improvements activities for both Medicare and Commercial populations.
• Directs data collection for HEDIS and CMS Star Ratings; identifies opportunities for improvement based on results.
• Influences all stakeholders to support key quality projects/programs to ensure positive solutions that deliver results.
• Collaborates with department leaders on initiatives to improve overall Star Ratings including clinical, Health Outcomes, CAHPS and pharmacy measures.
• Develops and distributes educational information to members and providers in accordance with HEDIS outreach work plans.
• Identifies potential resources and initiates collaboration with providers to improve member health outcomes and member experience.
• Leads coordination and management of Quality Improvement/Utilization Management (QI/UM) Committee and presents policy, programmatic, and work plan changes as appropriate.

Requirements

• Thorough knowledge of Quality Improvement implementation and management, HEDIS reporting, industry accreditation processes (TJC, URAC, NCQA) and quality requirements for Centers for Medicare & Medicaid Services (CMS).
• Absorbs compliance with all State and Federal quality regulations, URAC Quality Standards, and NCQA Quality Standards.
• Provides direction setting and leadership, with accountability for quality programs, specialized audits, special reviews, projects, and initiatives.
• Manages complex projects, people, and business priorities to achieve member satisfaction.
• Advanced problem resolution skills.
• Leadership ability to plan, organize, and execute multiple functional business objectives required.
• Demonstrated leadership ability to plan, organize, and execute multiple functional business objectives required.
• Preference given to applicant with NCQA/URAC accreditation experience.

Qualifications

• Bachelor of Science in Nursing required. Master’s Degree in Nursing or other related Health Care field preferred.
• Minimum of five years’ clinical and/or managed care experience required, including three years of experience in a managerial position.
• HEDIS or other regulatory (CMS, URAC, NCQA) quality audit experience preferred.
• Current State of Nevada Registered Nursing License required.
• CPHQ or ABQAURP Certification preferred.

Skills and Abilities

• Advanced qualitative and quantitative analytical skills.
• Excellent oral and written communication skills and ability to synthesize information from multiple sources into cohesive document or project plan.
• Strict adherence to rules and regulations for maintenance of confidentiality of peer review and member medical information.
• Advanced problem resolution skills.
• Leadership ability to plan, organize, and execute multiple functional business objectives required.
• Thorough knowledge of structure of health care delivery systems within managed care.
• Ability to maintain effective working relationships with internal staff, physicians, other providers, staff, employers, regulatory agencies, and enrollees.
• Excellent communication skills and experience communicating at all levels within the organization.
• Must be highly organized and be able to establish priorities and be proficient in use of word processing, spreadsheets and graphic applications.