Accountable for developing quality and continuous improvement strategies, and directing implementation that delivers operational excellence, resulting in higher quality performance. Responsible for the development and coordinating various quality improvement program related activities, objectives, and analysis related to ongoing development, maintenance and evaluation of quality systems and strategies focused on NCQA, 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, 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, Medicaid Quality Incentive Award (QIA) Program, Medicare Stars, QRS Stars, NCQA accreditation, QARR, and other regulatory and contractual compliance. Ensure cross-functional collaboration that improve quality of care deliver, member experience and outcomes.
Strategic Planning & Performance Management Support:
- Support quality strategy for value-based payment models and new methods to measure clinical quality for individual and population health
- Support clinical improvement initiatives and incentive programs by providing actionable data in a timely and accurately manner.
- Oversee the formulation, direction, implementation, administration, supervision, and planning of enterprise-wide performance measurement based strategies relative to HEDIS/QARR 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.
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 EmblemHealth quality ratings (Medicare Stars, Quality Incentive Awards, Quality Rankings, Accreditation Status) occurs 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.
- Drive the definition, measurement, and implementation of behavioral health quality and process improvement projects that support corporate initiatives. Direct the review and analysis of quality related data to design, develop, monitor, and evaluate clinical and administrative service studies to support quality improvement activities and programs.
- Provide direction over the preparation, organization and monitoring of the HARP, Children’s Health and Behavioral Health Administration and the Clinical and Behavioral Health integration programs.
- Monitor compliance with NCQA, local, state and federal regulatory authorities’ requirements, including support of the health plan’s HEDIS, QARR, Quality Incentive Awards, and Star processes.
Member Engagement & Member Satisfaction:
- Oversee the quality department’s member engagement efforts by developing year-round campaign strategy and parameters.
- Improve core process efficiency, 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 Voice of the Customer and Business data to scope the level of improvement required to impact customer loyalty and bottom-line results.