Resp & Qualifications
Purpose: The incumbent acts as the expert clinical practitioner responsible for providing thought leadership, consultation, and expertise for quality measurement for hospitals and specialists. The incumbent directs the quality review and quality improvement activities supporting the identification, monitoring, and certification of quality measurement activities. In partnership with others throughout the organization, the incumbent develops and oversees evidence-based measurements for clinical care and service in support of 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:
1. Leads implementation of and/or identification of key evidence-based valid and reliable quality measurements to support high performance networks and incentive-based contracts;
2. Collect, analyze and act on identified and mandated quality measures;
3. Collaborate with internal and external customers to improve triple aim outcomes;
4. Represents Clinical Innovations department in CareFirst quality initiatives such as QI Committee, improvements for HEDIS/STARS and other mandated quality measurements; and
5. Serves as primary representation for CareFirst’s commitment to specialist and hospital quality through accreditation and regulatory compliance.
Under the direct supervision of the Senior Director, Clinical Innovations, the incumbent’s accountabilities include, but are not limited to, the following:
1. Implement the corporate specialist/hospital quality measurement program
This clinical quality thought leader utilizes healthcare knowledge, business acumen and data fluency to drive quality improvement throughout the organization.
- Implements the annual regulatory quality reporting plan for the organization.
- Collaborates with senior leaders in establishment of goals and strategic direction.
- Provides expert medical consultation and technical advice to executive management in the evaluation of utility and validity of measurement systems and quality tools.
- Utilizes results from population-based quality and satisfaction measurement to inform quality improvement interventions for the organization.
- Monitors and evaluates the performance of interventions undertaken and recommends future course of action; andRepresents CareFirst as the Quality Leader through interactions with regulators, accreditors and key business partners shaping the future direction of healthcare policy.
2. Collect, analyze and act on mandated quality measures
This CareFirst quality champion is highly influential in establishing the culture of the organization dedicated to obtaining complete and accurate data. Establishes and maintains effective relationships throughout the organization, being the trusted partner, retrieving and abstracting clinical data, clinical practices providing care and with external regulators, this thought leader assures compliance and drives improvement.
- Provides clinical leadership and authoritative recommendations and guidance regarding clinical aspects of quality reporting, electronic clinical quality improvement, electronic health record interoperability and standards and tools related to quality measurement; Becomes subject matter expert for the organization by maintaining current knowledge of accreditation, regulatory and healthcare quality, clinical practices, and quality measurement requirements for specialists and hospitals and use of same.
- Leads quality reporting initiatives and executes projects to assess health outcomes and status in CareFirst, CMS, OPM, NCQA and state-based specialist and hospital based reporting systems.
- Develops and executes a plan to monitor compliance to accreditation and regulatory requirements and engages functional leaders to support quality efforts.
- Utilizes lessons learned and industry best practices to drive improvement.
3. Collaborate with internal and external customers to improve triple aim outcomes
- Collaborates in the development, implementation and evaluation of quality reporting programs for specialists and hospitals and policy for incentive based external and external programs.
- Leads an interdisciplinary team of individuals throughout the organization, including IT, Market Research, Medical Management, Networks. Legal and others.
- Acts as a contributing partner in the acquisition of clinical data from our clinical data aggregator and alternate sources as necessary to move beyond process measurement to that of outcomes.
4. Represents Clinical Innovations department in CareFirst quality initiatives such as QI Committee, improvements for HEDIS/STARS and other mandated quality measurements
- Current health care license to practice in MD, DC and VA and with no restrictions.
- 5-7 years of increasingly responsible clinical experience, with an emphasis quality.
- Demonstrated advanced knowledge and skills in the areas of clinical expertise, evidence-based specialty and hospital practice and providing the related consultation, education and mentoring.
- Experience with Project Management in a clinical or quality environment
- Proven capacity to perform qualitative and quantitative data analyses and create innovative strategies and work with colleagues to address findings;
- Demonstrated knowledge in technical aspects of collection and reporting of both administrative and clinical aspects of quality measures
- Exhibits ability to model excellence in advanced clinical practice within a specialty population.
- 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. Must be able to meet established deadlines and handle customer service demands from internal and external customers, within set expectations for service excellence. 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.
- This position where the incumbent must be capable of working with minimal oversight, showing keen attention to detail and making critical decisions.
- Excellent verbal and written communications.
- Must be a critical thinker who uses sound critical judgment in the evaluation of performance throughout the organization.
- Must possess data fluency and be skilled in analyzing and presenting data.
- Able to motivate people and influence change in a complex organization.
- A master’s degree in nursing or other health care related discipline, or equivalent experience.
- Broad knowledge of the healthcare industry including both clinical and operational aspects of Health Insurance Plan and products.
- Training or certification in Quality or Process Improvement Methods – or related training in an analytic field, including engineering, public health, management consulting or data science.
- Readiness to assume managerial-level responsibility, including motivating internal and external customers.
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: 6/30/2019
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 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 associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship