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Health Plan Quality Manager (Hybrid Work)

2131 South 17Th Street
Wilmington, NC
Job ID: 11072
Date Posted: Oct 7, 2022

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Job Description

Description

About NHRMC

NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.

About the Job

Location: New Hanover Regional Medical Center

Department: Population Health

Full Time Equivalent: FTE: 1.000000

Work Type: 64 to 80 Hours Pay Period

Work Schedule: STD HRS - Standard-Exempt; HYBRIT WORK 

Exempt from Overtime: Exempt: Yes

What You'll Do

Summary:

The HEDIS/Stars Quality Manager works under the direction of the Director of Clinical Operations in partnership with the Population Health team and other key stakeholders to drive all performance outcomes while consistently implementing programs designed to achieve results top-performing results (e.g. at minimum 4 out of 5 Star quality rating). These initiatives should result in a network of providers and stakeholders understanding and supporting the vision to transform healthcare delivery towards value for all populations. The responsibilities of this position demand a wide range of capabilities including: strategic planning and analysis skills to drive performance; strong understanding of HEDIS and coding; management breadth to direct and motivate; highly developed communication skills; and the ability to develop clear action plans and drive process improvements, given often ambiguous issues with numerous interdependencies. He/she will manage quality and outcome metrics in accordance with accreditation agencies (e.g NCQA, URAC), regulatory guidelines (e.g. CMS, Medicaid), federal and state requirements, and any contractual performance obligations while supporting population health initiatives and practice operations to improve health outcomes, enhance patient satisfaction, and reduce total cost of care. As a subject matter expert for technical specifications of all metrics that serve various medical management programs to achieve the quadruple aim, this person will ensure EMR, analytics platforms, and other resources that incorporate outcome metrics are accurate and validated; develop and implement tailored initiatives that drive performance; and serve as a quality improvement coach to practices by developing successful workflows and identify meaningful trends/outliers to support successful value-based arrangements. This person works closely with all Population Health team members, practice providers, and other care personnel to educate, analyze data and help formulate quality improvement projects based on findings. This is a multifaceted role, incorporating expertise in clinical workflows, data analysis, and performance improvement methodologies in order to achieve measurable improvements while being self-directed. 


Responsibilities:

 1. Manages, monitors, and controls work progress on key metrics including but not limited to HEDIS / Stars and initiatives / action plans that impact quality and outcomes. Serves as a subject matter in developing and incorporating technical specifications for quality and outcome metrics in accordance with accreditation agencies (e.g NCQA, URAC), federal and state requirements, and any contractual performance obligations. 2. Participates in development and implementation of systems and processes that support quality operations and results. 3. Maintains effective cross functional services and communication by working effectively with stakeholders like population health, the health system, the health plan, and providers to ensure success of the performance goals 4. Analyzes data while collaborating and/or participating in discussions with colleagues and business partners to identify potential root cause of issues with the ability to develop solutions. 5. Demonstrates understanding of providers’ goals and strategies to facilitate analysis while handling provider inquires and/or problems with the ability to facilitate resolution. Continuously strives to ensure that favorable relationships are maintained while ensuring the interest of the organization. 6. Takes ownership of total work processes and provides constructive information to ensure physician partners have support to meet initiatives and work towards stretch goals. Helps practices utilize performance reports and patient risk scores to improve population health management initiatives. 7. Work with relevant stakeholders to identify obstacles and barriers with ability to removing them. 8. Communicate and advocate providers' needs to stakeholders in order to drive creation of solutions that meet performance goals 9. Communicate industry and company information to providers through various means to align all stakeholders towards value-based care (e.g., newsletters; emails; outreach calls; teleconference; conferences; on-site meetings) 10. Facilitates provider discussions and assists in negotiating resolution to escalated provider issues with the capability to determine if/when issues require escalation 11. Collectively works with cross functional leadership to eliminate duplication of efforts and member or provider abrasion. Provides hands on technical helps implement assigned rapid cycle performance improvement plans. 12. Empowers practice staff to use data to improve decision making at the point of care and to adhere to evidence based practice guidelines 13. Organizes and performs work effectively and efficiently, including communication that is clear in written 14. Demonstrates positive interpersonal relations in dealing with all members of the team as well as practices. 15. Organization, communication, and time management skills are essential; able to multi-task; work well with clients and within a team also essential 16. Performs other duties as assigned. 

Position Requirements

Education:

* Bachelors Degree

Other information:

1. Education: Bachelor’s degree in Nursing, Ancillary Health care, Health Care Administration, Business Administration, Public Administration, or a related field (Associate degree with 4+ years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree. Master’s degree in Healthcare Administration, Business Administration, or a related field preferred. 

2. 5+ years of related experience in Quality/ HEDIS/ CMS Stars, and ICD-10/ CPT/ CPT II coding knowledge, Provider relations required 

3. Knowledge of Medicare, Medicaid, and Commercial health plan quality operations including but not limited to HEDIS, Stars, Coding, and Medicare Advantage. 

4. Knowledge of accreditation, CMS guidelines, state/federal laws, and applicable regulatory guidelines related to Medicare, Medicaid, and Commercial business 

5. Advanced Microsoft Office skills; must be proficient in Excel. 

6. Strong knowledge of clinical standards of care, preventative health, and STAR measures preferred 

7. Strong financial analytical background within Medicare Advantage plans (Risk Adjustment/STARS calculation models) preferred 

8. Strong analytical skills with ability to effectively represent data through various modes of communication is preferred 


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