Under the direction of the Director, Quality Management, the Manager, Quality Management is responsible for providing oversight, daily administrative management, and direct supervision of the Quality Management team. This position is also responsible and accountable for maintaining the Health Plan’s compliance with all state regulations and NCQA standards for quality activities related to Quality Management. This includes managing medical policy development, quality of care, health promotion, HEDIS interventions, accreditation as well as committee structure and support.
Accountabilities:
- Responsible for the development, implementation and evaluation of the QM program (to include the work plan) and the Continuous Quality Improvement (CQI) plan under the guidance of the Chief Quality Officer.
- Participates in the planning, developing, and implementing Health Plan activities related to the HEDIS, CAHPS, accreditation, quality management programs, performance improvement projects, CLAS program, specified CMS Core Measures and AOP-specific initiatives. Identifies opportunities for clinical performance improvement and develops Quality Improvement Initiatives related to clinical performance and other quality activities.
- Maintains current knowledge of the Health Plan’s Policy and Procedures and ensures program compliance to the governing regulatory body, NCQA HP and MCH Standards, CLAS standards, HEDIS and CAHPS. Participates in oversight activities as required by regulatory and accrediting bodies.
- Identifies barriers to project and program success and works toward resolution by informing the accountable executives and presenting plans to resolve the issue when possible. Maintains monitoring of issue until resolution or decision by the accountable executive to discontinue efforts toward resolving the issue.
- Responsible for meeting budget, organizational and departmental goals. Maintains optimal staffing patterns based on current Quality Management budget.
- Responsible for the management and development of new and existing staff. Works collaboratively with Performance Management to identify educational needs to staff and to maintain appropriate clinical expertise required to successfully perform daily responsibilities. Participates as indicated in the development and implementation of orientation and ongoing educational programs.
- Analyzes quality data from all sources and directs to appropriate committees and or accountable executives. Performs ad-hoc analysis of any underperforming or “broken” processes by collaborating with Subject Matter Experts and/or Customers to define existing processes and make recommendations for improvement.
- Ensures the timely creation of project plans, including measurements of outcome and productivity, and reports out progress to key stakeholders.
- Prepares reports and assessments of operational/services as required by departmental, corporate, and/or regulatory requirements. Works collaboratively with the Medical Informatics Department on identifying required data for reporting.
- Provides input into the development of educational material and programs necessary to meet the Health Plan’s business objectives, members’ needs, regulatory guidelines and staff professional development.
- Works in a collaborative manner with providers, members, and departments within the AmeriHealth Caritas Family of Companies to conduct ongoing process and data review to identify opportunities for improvement.
- Participates in interdisciplinary committees to maintain understanding and participation in projects and policies related to compliance with quality standards and or quality initiatives.
- Participates in coordination of internal and external Provider and or Member directed communication regarding issues impacting Quality Management.
- Acts as liaison for Quality Improvement staff and represents plan on state committees and workgroups whose focus is quality improvement projects, including EQRO, PIPS and other state initiatives.
- Responsible for creation and submission of state compliance documentation of activities and projects in his/her scope of responsibility.
- Uses data and analysis tools to identify opportunities for improved performance and collaborates with peers to develop intervention strategies.
- Responsible for the NCQA accreditation processes, Multicultural Healthcare Quality Distinction and all related reporting and analysis activities to include: production of reports and analysis to support executive leadership decision making; QM Department data collection and analysis activities that support NCQA QI Standard compliance.
- Works collaboratively with the key plan leadership and other stakeholders to assure NCQA delegation oversight compliance and timely disbursement of NCQA compliant member and provider communications.
- Supervises the processes for schedules, work plans, agendas, and minutes for committees that are part of the Quality Committee structure, and assures timely and accurate preparation of Quality Documentation to the health plan governance structure.