Resp & Qualifications
Plan, organize, and direct a diverse staff and activities for Quality Improvement across Medicaid (MD), Dual Special Needs Populations (DSNP) & Medicare Advantage plans. Develop and operationalize a multi-year strategy for quality improvement, accreditation, compliance with NCQA HEDIS, state VBP (Value-Based Performance), and other quality regulatory standards (Performance Monitoring, EPSDT, System Performance Review (SPR), Encounter Data Validation, etc.)
Weight Essential Functions
Oversees the development and ongoing execution of Quality Improvement initiatives for Maryland Medicaid and Medicare Advantage (MA-PD/D-SNP) plans to improve HEDIS, Medicare Stars, State Value-Based Performance programs along with ensuring compliance with regulatory quality standards. Leads the organization and day to day activities of staff to oversee HEDIS improvement, Health Plan Accreditation, CAHPS/Customer Experience, External Quality Review (EQR), and other regulatory requirements that directly/indirectly impacts the Health Plans Quality performance.
In conjunction with quality directors/leaders supporting other CareFirst business lines, Stars & Risk adjustment, Clinical Care Management, Compliance, Government Programs & other cross-functional teams develop, prioritizes, and operationalizes Quality Improvement initiatives.
Evaluates & trends the health plan quality performance using evidence-based and data-driven approaches against the market/industry performance. Oversees development and communication of scorecards outlining the progress/trends of quality goals and outcomes, efficacy & barriers (if any). Actively participates with the State (MD), CMS, NCQA & Industry workgroups assigned to represent the plan on behalf of Quality & champion/advocate for the plan's quality improvement & population health.
Directs the strategic and the day-to-day activities of the Quality department, including coaching and guiding individuals and teams to implement departmental, divisional, and organizational mission/goals. Recruits retain and develop a high-performing team. Evaluates each team member's performance, generates development plans, and sets goals within corporate policies and procedures. Develops annual goals, prepares, monitors, and analyzes variances of departmental budgets to control and appropriately allocate resources.
Maintains knowledge of current and future NCQA, NQF, CMS/Federal, Maryland State regulatory and healthcare quality measurement requirements and accreditation standards. Leads and participates in large group presentations & relevant committees.
# of Direct Reports: 5-10
# of Indirect Reports: 15-20
Freedom to Act
Work is accomplished without considerable direction. Exercises judgment in selecting methods, techniques, and evaluation criteria in obtaining results. Exerts significant latitude in determining objectives of assignment. Takes calculated risks with consultation from the expert.
Problem Complexity and Problem-Solving Timeframes
Works on significant and unique issues where analysis of situations or data requires an evaluation of intangibles. Aware and responds to changing and interconnected variables. Exercises independent judgment in methods, techniques, and evaluation criteria for obtaining results. Problem/Task resolution timeframe: Inclusive of shorter timeframes, but typically twelve months or more to resolve.
Level of Supervision Received
Uses policies and general objectives with little functional guidance. Rarely refers specific cases to the manager unless clarification or interpretation of organization policies is involved.
Failure to obtain results or erroneous judgments or recommendations would normally have serious results and may require the substantial expenditure of resources to correct and / or achieve goals.
Contact with Others
Represents the organization as the primary contact. Interacts with management and senior value-chain partners on matters requiring coordination across organizational lines. Achievement of objectives requires ability to influence others both internally and potentially externally.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Bachelor's Degree
Education Details: business administration, health policy, health services research, public health, economics, mathematics, computer science, or a related field
Experience: 8 years’ experience in healthcare, public health, health insurance, quality/process improvement, or data management business environment
At least three years of management experience
In lieu of a Bachelor's degree, an additional four years of relevant work experience is required in addition to the required work experience.
Training or certification in Quality or Process Improvement Methods
Clinical Qualification (RN/NP/PharmD)
Data Analytics & Visualizations
Knowledge, Skills, and Abilities (KSAs) Proficiency
Ability to perform qualitative and quantitative data analyses and create innovative strategies and work with colleagues to address findings; and Advanced
Ability to learn the technical aspects of collection and reporting of both administrative and clinical aspects of quality measures. Advanced
Strong computer skills to include Microsoft Office Advanced
Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed. Ability to lead and direct analysts, clinicians, and project/program managers. Advanced
Public speaking and presentation skills Advanced
Deep understanding of the Customer Experience Advanced
Experience in Population Health Management Concepts Advanced
Additional Skills and Abilities
Extensive experience and expertise in Maryland Medicaid, Medicare Advantage/Dual SNP plans.
Proven ability to lead quality improvement initiatives to improve HEDIS, Medicare Stars, State Value-Based Performance programs and ensure compliance with NCQA & other regulatory quality standards.
The incumbent is required to immediately disclose any debarment, exclusion, or other events that make him/her ineligible to perform work directly or indirectly on Federal health care programs. 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. Must meet established deadlines and handle multiple 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.
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: 4/11/2021
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