Provides leadership for all activities relating to continuous quality improvement and accreditation activities including National Committee for Quality Assurance (NCQA), CMS STARs Ratings, and clinical quality programs. Oversees the Office of Clinical Affairs (OCA) project management functional area. Develops and oversees policies and processes to ensure implementation of programmatic initiatives, such as improved behavioral health and medical integration. Provides quality improvement, expertise to corporate wide initiatives. Supports the Vice President of Quality and Clinical Program Oversight and participates in developing and implementing business plans in the Clinical and Quality Management area to support the Plan’s strategy.
Designs, implements and leads the Plan’s continuous quality improvement inf Acts as an internal consultant and resource to all levels of the organization relative to CQI processes and standards. Keeps abreast of New Hampshire Department of Health and Human Services (DHHS), MassHealth, CMS and the Qualified Health Plan strategic goals to ensure processes, plans and policies are designed to fulfill strategic objectives, such as improved integration of Behavioral Health and medical management. Leads all Plan activities in application for NCQA re-accreditation and addition of new products to current accreditation including development and execution of improvement strategies for HEDIS, CAHPS and STARs Ratings
Drafts as well as reviews and edits documentation (e. request for proposals) on behalf of the Vice President of Quality and Clinical Program Oversight as directed.
As part of senior management in the Clinical and Quality Management area, participates in OCA strategic planning and provides Vice President of Quality and Clinical Program Oversight and Chief Medical Officer with timely and accurate information.
Serves as the OCA liaison to the Credentials Committee.
Supports corporate strategy and contributes to request for proposals to support growth of new business or maintain current contractual agreements.
Directs the HEDIS audit process including pre-audit preparation of systems and processes with internal and external customers (vendors, department directors, etc), on-site process, and post audit process. Works with the Manager of HEDIS Program Performance and the HEDIS auditor to ensure accuracy of data and systems to produce unbiased HEDIS results, including data validation and researching variances among the HEDIS measures.
Ensures the development, implementation and evaluation of the annual HEDIS project plan for pertinent cross-departmental staff and contracted vendors to meet HEDIS, CMS and state (DHHS and EOHHS) deliverables.
Supports the analysis of year over year HEDIS rate reviews. In cooperation with the Director of Quality Improvement Operations conducts a thorough root cause analysis on significant rate changes.
Liaises with the Plan’s HEDIS software vendor and manages the contract.
Ensures HEDIS Data are reported to state, federal and regulatory bodies as required contractually and to maintain NCQA accreditation.
Responsible for the ongoing administrative, clinical, fiscal and programmatic interaction with NCQA, DHHS, CMS and EOHHS as it relates to accreditation and measurement activities.. Communicates with NCQA as needed to ensure the Plan is informed of all events and circumstances that affect the on-going achievement of NCQA accreditation.
Ensures compliance with MassHealth contractual requirements relative to Quality Management / Quality Improvemen Supports Plan-wide activities related to oversight of other Medical Record Review Audits, including QHP RADV (Risk Adjustment Data Validation), and NH Medicaid/DHHS Hybrid CMS measure development per reporting requirements. .Ensures compliance with DHHS, CMS, Connector and Division of Insurance contractual and regulatory requirements relative to quality measurement.
Directs quality of care studies (based on targeted areas for quality management and quality improvement). Oversees analysis of data, root cause analysis, plans for improvement, technical support to Plan managers, and re-measurement activities to assess performance improvemen
Monitors quality performance indicators; prepares reports for quality oversight committees; develops vehicles to communicate performance to providers; and identifies clinical and administrative concerns for further investigation and analysis.
Develops and manages communications with providers, government and accreditation organizations with respect to results of quality management studies, including oversight of remedial action as require
Oversees the project management function for clinical areas within OCA. Supervises PM staff.
Directs the supervision of subordinate staff to include hiring, work allocation, scheduling, training and professional development, problem resolution, performance evaluation and related supervisory activiti Maintains budgetary responsibility for the department.
Other duties as assigned.
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Bachelor’s degree in Health Care Administration, Public Health, Nursing, or related field or the equivalent combination of training and experience is required.
Master’s degree in Public Health, Public Administration or Public Policy preferred.
10+ years progressively responsible experience in leading Quality Improvement Programs, which includes supervision of staff and budget management, is required.
3-5+ years clinical nursing experience preferred.
Comprehensive knowledge of Medicare, Medicaid and MassHealth regulations, guidelines and standards is required.
Comprehensive knowledge of accreditation organizations such as NCQA is required.
Experience within a managed care organization is strongly preferred.
Previous experience in designing and leading an accreditation process is strongly preferred.
Certification or Conditions of Employment:
Registered nurse with active license.
CPHQ certification preferred.
PMP Certification preferred
Competencies, Skills, and Attributes:
Comprehensive knowledge of QM/QI standards, processes and metrics; including HEDIS, STARs, CAHPS, and CMS is required.
Proven leadership skills and ability to build effective teams and direct the management of multiple, complex, high impact projects is required.
Outstanding oral and written communication skills.
Ability to build relationships and successfully interact with staff at all levels of the organization and with external constituencies.
Internal Number: 2013954
About BMC HealthNet Plan
BMC HealthNet Plan is a non-profit managed care organizations committed to providing the highest quality healthcare coverage to underserved populations. In Massachusetts, BMC HealthNet Plan is the business name for Boston Medical Center Health Plan, Inc.; outside Massachusetts, Well Sense Health Plan is the business name.