Manager of Quality Improvement

The Manager of Quality Improvement supports the Senior Manager of Quality Improvement and Accreditation by leading the identification and design of company-wide quality improvement (QI) efforts and provides direction to the implementation of QI efforts through cross-functional work teams, department workgroups and/or other ad hoc teams. This position leads the organization’s efforts to obtain the highest level of performance in quality measures including NCQA Medicaid Health Plan Ratings, Medicare Stars and pay for performance programs.

Duties and Responsibilities

Responsibilities include, but are not limited to, the following:

• Works with internal committees and inter-departmental work groups to identify and prioritize innovation and improvement opportunities. Helps align senior leader support for suggested organizational changes/projects and presentation to selected audiences
• Monitors performance of HEDIS and Stars measures and develops processes to support continuous quality improvement
• Leads and oversees the development and implementation of programs and interventions to optimize HEDIS, Stars and other quality performance programs
• Evaluates effectiveness of quality improvement initiatives, including providing recommendations to internal and external stakeholders
• Develops and monitors provider quality score cards to ensure ongoing provider engagement in quality improvement activities to maximize performance in HEDIS and Medicare Stars measures
• Provides subject matter expertise in support of the agenda and work of quality improvement committees
• Engages in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
• Serves as the subject matter expert on models for quality improvement methods, standards, and applications, and for data management and display related to QI
• Assists other departments with business process/quality improvement projects
• Supports the analysis of annual HEDIS data and the information on performance from NCQA Health Plan Stars Rating to help identify high-priority improvement and innovation opportunities for the organization
• Leads cross-functional inter-departmental team which plans, organizes, coordinates and identifies improvement opportunities in support of achieving the highest level of NCQA Health Plan Stars Rating for Medicaid, Medicare and commercial products

• Responsible for the organization’s bi-annual filings with the Office of the Health Insurance Commissioner (OHIC) to obtain Network Plan and the Benefit Determination and Utilization Review Certifications

• Maintains current knowledge of all present and future quality mandates from regulatory bodies including NCQA, Executive Office of Health and Human Services, Centers for Medicare and Medicaid Services and other regulatory bodies
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Required:

• Bachelor’s degree in Business Administration, Health Care Administration, Public Health or related field
• Five (5) years’ experience in a managed care organization or a health care-related organization, including experience with Medicaid and/or commercial lines of business
• Knowledge and experience in data collection, specifications, and key performance drivers of all Stars measures
• Demonstrated knowledge in using quality improvement tools and techniques to drive performance
• Two (2) or more years of direct experience facilitating and/or leading quality improvement or business process improvement efforts, preferably related to health care
• Two (2) or more years of experience overseeing teams/management experience
• Experience with NCQA accreditation survey requirements for health plan, HEDIS quality measures and with state and federal health care regulations applicable to managed care organizations
• Experience in providing leadership to formal and informal group processes supporting priority setting and program implementation
• Experience in management and supervision of staff, including staff with technical responsibilities
• Must be detailed-oriented, able to exercise sound judgment in making decisions, able to work independently in a flexible environment and able to manage multiple projects in an efficient, timely manner
• Strong ability to conduct both quantitative and qualitative analysis and identify opportunity for improvement as well as activities to address the opportunities
• Strong ability to represent the company in statewide initiatives
• Strong presentation, project management, interpersonal and oral and written communication skills
• Strong ability to foster an environment of learning and empowerment
• Strong computer skills required (Excel, Word, PowerPoint, MS Project research)

Preferred:

• Masters degree in Business Administration, Health Care Administration, Public Health or related field
• Demonstrated experience with Medicare Stars
• Experience developing and implementing pay for performance programs including value-based approach
• National Association of Healthcare Quality certification as a Certified Professional in Healthcare Quality/Organizational Excellence (CPHQ/OE) or similar QI training

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.