Resp & Qualifications
Purpose: The Specialty Quality Measurement Expert is part of a team responsible for helping to ensure that our members receive the highest quality care and service possible. This individual, in collaboration with others across the organization, is responsible for quality measurement collection and will use data to identify opportunities and work throughout the organization and within our provider network to implement quality improvement interventions.
This individual will champion quality improvement across the company for specialists. Through relationships with key leads throughout the organization, they carry out the QI Program goals and objectives leading to compliance with regulatory and accreditation requirements and progressively increasing health plan performance and patient outcomes.
This individual is a part of a team of quality professionals to achieve the triple aim: improving health outcomes, reducing cost of care and improving the overall experience for members; as well as, physician satisfaction through the following:
- Carries out the region-wide quality improvement (QI) program;
- Collects, analyzes and reports on mandated quality assessments; and
- Leads Specialty Health Quality Improvement activities.
Under the direct supervision of the Sr Director, Clinical Innovations, this associate’s accountabilities include, but are not limited to, the following:
1. Carries out the corporate QI program
The Specialty Quality Measurement Expert, utilizes healthcare knowledge, business acumen and data fluency to drive quality improvement throughout the organization.
- Collaborates with functional leads throughout the organization to integrate Specialty Health aspects into the QI program and assure compliance with contractual, regulatory and accreditation requirements;
- Uses performance data from quality measurement and QI activities to improve the quality and safety of specialty clinical care and services provided to CareFirst members;
- Supports the establishment of specialty specific performance targets for value-based contracting;
- Analyzes and evaluates the effectiveness of quality measurement and activities to identify and prioritize opportunities and gaps in care;
- Utilizes results from population-based quality and satisfaction measurement to inform quality improvement interventions for the organization;
- Assures integration of specialty health aspects within CareFirst policies, standard operating procedures, guidelines, programs and communications;
- Represents the specialty health perspectives in the QI Committees to improve the quality and safety of specialty health clinical care, safety and services;
- Contributes specialty health data and reports to the annual workplan and QI program evaluation; and
- Utilizes results to inform program effectiveness and appropriate modifications.
2. Collects, analyzes and reports on quality assessment
Through effective relationships throughout the organization, with trusted partners, clinical practices providing specialty health care and with external regulators, the Specialty Quality Measurement Expert assures compliance and drives improvement.
- Maintains knowledge of current and proposed accreditation standards, regulatory and healthcare quality, clinical practices, and quality measurement requirements and standards and measures specific to the specialties being measured;
- Participates in a strategy to acquire clinical data for accurate and reliable measurement of performance;
- Collaborates with functional leads and network providers throughout the organization to collect and analyze quality assessments for all aspects of specialty health plan operations, clinical care, network adequacy, experience of care and safety;
- Oversees performance of Delegated functions/ Vendor activities; as applicable;
- Supports and Oversees the collection of specialty health HEDIS and other evidence-based quality measurement;
- Analyzes processes, results and data trends to identify and prioritize opportunities;
- Utilizes lessons learned and industry best practices to drive improvement;
- Leads multidisciplinary work team(s) in improvement activities for prioritized opportunities; and
- Coordinates, facilitates, documents and reports on all aspects of assigned project(s).
3. Leads specialty health quality improvement activities
- Coordinates and leads QI related committees and/or work teams to collect and evaluate performance in the following areas for specialty healthcare and services:
- Experience of care
- Appropriate utilization and resource use
- Conducts both quantitative and qualitative analysis to identify and prioritize opportunities for improvement;
- Analyzes processes, results and trends to recommend actions to implement QI activities that drive continual improvement;
- Works with internal teams and specialty groups on improvement efforts;
- Measures the effectiveness of improvement actions; and
- Creates executive level and front-line reports and presentations.
- Bachelor’s Degree in clinical discipline, Health Care Administration, Population Health, Public Health or other degree in healthcare related field. In lieu of Bachelor’s degree, must have 4 years’ experience in a discipline related to specialty type care.
- 2+ years of professional experience in business environment (healthcare, public health, health insurance, quality/process improvement or data management);
- Proven capacity to perform qualitative and quantitative data analyses and create innovative strategies and work with colleagues to address findings; and
- Ability to learn the technical aspects of collection and reporting of both administrative and clinical aspects of quality measures.
- Excellent verbal and written communications;
- Must be a critical thinker who uses sound judgment in the evaluation of performance throughout the organization;
- Must possess data fluency and be skilled in analyzing and presenting data;
- Broad knowledge of the specialty healthcare industry including both clinical and operational aspects of Health Insurance Plan and products (preferred); and
- Able to motivate people and influence change in a complex organization.
- The incumbent must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. The incumbent must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. The incumbent must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
- The Candidate must demonstrate excellent computer skills and knowledge of multiple software systems, such as Microsoft Word, Outlook, and Excel
- Master’s Degree in a clinical discipline, Health Care Administration, Population Health, Public Health or other advanced degree in healthcare related field
- Active involvement in collection and/or submission of established clinical quality measures
- Training or certification in Quality or Process Improvement Methods
- Related training in an analytic field, including engineering, public health, or data science
Department: Accreditation & Medical Program
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 1/15/2019
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described below are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Occasional driving is required.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship