Job Summary

Accountable for developing quality and continuous improvement strategies, and directing implementation that delivers operational excellence, resulting in high performance in CMS’ STAR’s program. Responsible for the development and coordination of various quality improvement program related activities, objectives, and analysis related to ongoing development, maintenance and evaluation of quality systems and strategies focused on HOS, HEDIS, and CAHPS for all products and services. Provide oversight and leadership of Quality Management, including Behavioral Health, Performance Improvement and initiatives, Regulatory Quality Programs, and Member Engagement functional areas. Responsible for the reporting and analysis of quality of care concerns and for the development of plans and programs to support continuous quality improvement using HEDIS, HOA, CAHPS and other tools. Support activities and processes related to compliance with NCQA, local, state and federal regulatory authorities. Support the annual HEDIS submission for Managed Care Organizations, Medicare Stars, HOS, CAHPS, and other regulatory and contractual compliance. Ensure cross-functional collaboration that improves quality of care delivery, member experience and outcomes

Functions & Job Responsibilities

• Oversee the formulation, direction, implementation, administration, supervision, and planning of enterprise-wide performance measurement-based strategies relative to HEDIS/STAR measures.
• Drive the definition, measurement, and implementation of quality process improvement activities and projects in support of corporate goals.
• Direct the review and analysis of quality related data to evaluate clinical and administrative service improvement activities and programs.
• Prepares weekly, monthly, and quarterly reports for internal dashboard reporting
• Leads teams, coaches and strategically develops staff expertise in alignment with Department objectives
• Develops and updates written department policies and procedures
• Oversees implementation of new processes and new technology in Quality Management
• Ensures staff performance standards are consistently met

Quality Management Programs & Initiatives:

• Responsible for ensuring that the definition and formulation of data-driven strategies, as well as the management and operational activities across Quality Management, Medical Management, Pharmacy Services and other areas of the organization are designed to increase Clever Care Health Plan quality ratings (Medicare Stars, Quality Incentive Awards, and Quality Rankings) occur in an efficient and effective manner, and in compliance with NCQA, state and federal regulations and requirements.
• Collaborate with other areas of the company, external vendors and medical groups to improve or maintain healthcare quality metrics and outcomes.
• Oversee team that investigates and resolves/tracks quality of care issues that come from members/providers/UM process.
• Support the implementation of the Member Rewards Program implementation and ongoing monitoring across the enterprise.

Member Engagement & Member Satisfaction:

• Oversee the quality department’s member engagement efforts by developing year-round campaign strategy and parameters.
• Improve core process efficiencies, effectiveness and responsiveness; measure and improve business critical operational KPIs/metrics, especially in the areas of customer satisfaction/loyalty/retention, and provider access and availability.
• Direct the application of the Customer and Business data to scope the level of improvement required to impact STARs ratings, customer experience and loyalty and bottom-line results.

#LI-Hybrid

Education:

• Bachelor’s degree in Business, Healthcare, or related field required. Master’s degree preferred.

Experience:

• Minimum of 5 years in healthcare/managed care industry with experience in HEDIS/Medicare/Stars/CAHP and HOS program management and leadership; Health Plan experience preferred
• Experience in program performance measurement, analytics, reporting and forecasting for Quality programs and measures

Skills:

• Exceptional presentation skills to a variety of audiences including leadership teams, clinicians, and office staff.
• Knowledge, understanding, and accurate interpretation of product line related specifications, methodologies, and processes, and of HEDIS/HOS/CAHPS processes
• Excellent leadership skills and the ability to influence line management decisions with data driven facts
• Strong management, problem solving, priority setting skills
• Strong independent decision-making skills
• Strong organizational skills including time and project management skills
• Computer proficiency in MS Office applications (word processing, spreadsheet/database, presentation)
• Possess strong results-oriented process improvement capabilities
• Strong problem solving and analytical skills to be applied to a wide array of business problems and challenges
• Solid change leadership, facilitation, oral and written communication, and presentation skills
• Detail oriented with exceptional written and verbal communication skills
• Ability to maintain composure and effectiveness in a rapidly changing environment with minimum direction
• Must be a self-starter and independent thinker

Physical & Working Environment.

Typical Physical Demands.
Position requires a great amount of driving, sitting and standing. Some standing, stooping, bending or reaching is required. May require lifting up to 15 pounds. Requires manual dexterity sufficient to operate a computer, calculator and telephone. Requires normal range of hearing and vision. Requires the ability to type and file.

Typical Working Conditions.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. Work may be stressful at times. May occasionally work some irregular hours.

What’s in it for you?

1. A competitive compensation and benefits program (Salary is negotiable depending upon experience).

2. 15% Annual Incentive Plan bonus.

3. Generous paid-time-off (PTO).

4. Eleven paid holidays per year.

5. Excellent 401k saving plan, employer provides up to 4% match and employer contribution match is 100% immediately vested.

6. Non-Voting Stock Options.

7. Work-Life balance and much more!

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.