Job Description

Position Purpose: This position is responsible for coordinating and implementing quality initiatives and overseeing projects in order to continuously improve all aspects of health care delivery for Medicare and Medicaid lines of business. This includes communication and monitoring of Risk Adjustment, HEDIS, STAR measures, Special Investigations and Fraud, Waste, and Abuse, as well as promoting culture changes that support an environment of quality and Star measure success within Steward Health Choice Arizona (SHCA) and Steward Health Choice Utah (SHCU) – Western Region. This position also establishes and improves risk adjustment and quality performance metrics, business operation service development, and process design teams to promote education and cultivate relationships, as well as aiding with the strategic planning for business development activities for the organization.

  • Leadership and support in establishing and directing the Quality and Risk Adjustment Programs consistent with organizational activities;
  • Responsible for all activities related to National Committee for Quality Assurance (NCQA) Accreditation, Utilization Review Accreditation Commission (URAC) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance ensuring highest level of accreditation;
  • Manage aspects of Quality / HEDIS improvement activities, including outreach, incentives, data integrity and chart review;
  • Provides expertise and training on Risk Adjustment, HEDIS, and Star measures and tools that support collection of and communication about these programs;
  • Coordinates reporting on quality initiatives to all appropriate committees and ensures timely submission of data and metrics;
  • Accountability to Medicare and Medicaid business leaders for achieving measurable targets established by the organization to achieve strategic goals and business vision;
  • Facilitates and manages PCP onboarding functions to develop technical skills, set performance expectations, evaluate outcomes, and implement training and education efficiently and effectively as it relates to Risk Adjustment, HEDIS, and Star measures;
  • Provides oversight and guidance on project management timelines and process improvement, implementation, and development for clinic operations in support of organizational objectives, policies, and procedures;
  • Manage and ensure compliance of Medicaid Managed Care performance measures, such as EPSDT program, as well as assist in compliance and turnaround time of grievances and appeals;
  • Review and implement new technological tools and processes and foster team concept with internal and external constituencies;
  • Present results of improvement efforts and ongoing performance measures and recommend actions plans to senior management;
  • Research and incorporate quality improvement best practices into operations;
  • Improvement of efficiencies by research of best practices and identifying new / needed skills, processes, or methods to improve operations center;
  • Leads and coordinates Fraud, Waste and Abuse (FWA) and Special Investigations Unit (SIU) operations within the health plan and internal functional teams to assure smooth workflow exists and quality assurance measures are designed and monitored;
  • Maintain an effective payment integrity program for all lines of business by promoting ethical practices and a commitment to compliance with applicable federal, state, and local laws, rules, regulations and internal policies and procedures related to detecting, correcting, and preventing fraud, waste and abuse;
  • Responsibilities may include responding to external audits, coordination of state readiness reviews, policy and procedures development, prepayment review oversight, regulatory reporting oversight, maintaining a schedule of active corrective action plans and follow-up activities;
  • Drives efforts to identify and resolve over payments and to detect, correct, and prevent FWA incidents in an overall payment integrity framework;
  • Creates and manages effective monitoring metrics to drive key performance indicators tracking and cost avoidance tracking;
  • Assures an adequate quality assurance program and process are in place and strictly adhered to for all tasks;
  • Directs training for SIU unit personnel on internal and external protocols and systems and investigative techniques;
  • Capitalizes on opportunities to create pre-payment edits for recurring over payment instances with cross functional teams, and drives cost avoidance measures.

Education / Experience / Other Requirements

Education:

  • Bachelor’s Degree from an accredited college or university preferred. Field of study: business, math, finance, economics, actuarial science, healthcare administration, nursing or related clinical field or other related health care field. Equivalent experience may be considered in lieu of degree.

Years of Experience:

  • 5 or more years of healthcare operations experience, including quality improvement, risk adjustment, URAC and NCQA accreditation experience.

Specialized Knowledge:

  • Familiarity with running Risk Adjustment prospective and retrospective programs preferred
  • Experience managing acquisition and integration of external data sources.
  • Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
  • Demonstrated success leading cross-functional teams. Ability to prioritize tasks with competing deadlines.
  • Certified Professional Coder, Certified Professional in Health Care Quality or RN license preferred.

Application Instructions

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