Experienced leader responsible for NCQA Health Plan Accreditation, HEDIS activities related to quality projects required by CMS for Medicare Advantage, ACA and FEHB that will optimize or improve the health and experience of members while reducing costs of care. Leads NCQA surveys, and participates in CMS audits. Manages staff responsible for working collaboratively and cross-functionally corporate-wide to assure quality projects, processes, reports, materials and files comply with standards/regulations at the highest level and follow valid methodology. Implements workflows to assure delegates and/or downstream entities comply with NCQA and CMS. Oversees annual over-read process of HEDIS clinical data. Supports oversight of quality committee structure.
Leads all aspects of NCQA accreditation including application, surveys and file reviews.
Develops, monitors and maintains corporate-wide processes and projects that promote attainment of maximum points allowed for all NCQA standards.
Develops, implements and submits quality projects required for all federal programs. Assures periodic reporting.
Coaches and trains employees across the organization to assure that best practices are disseminated and incorporated across the company to support accreditation.
Facilitates multi-disciplinary teams or work groups including Stars that collaborate cross-functionally on processes, reports and materials to meet requirements.
Monitors ongoing changes and initiates steps to mitigate risk as needed.
Collaborates with Chief Medical Officer and VP, Quality on agenda and presentations for quality committees.
Reviews all written reports to assure valid methodology is followed and reports are timely and well-written, using proper grammar, punctuation, etc.
Develops, monitors and maintains internal processes and systems to assure clinical grievances from Medicare Advantage members are handled timely, completely and accurately according to CMS regulations and policies. Tracks inventory and assures information is in place for HPMS reporting.
Reviews clinical grievances and assists nursing staff in facilitating resolution. May contact members or providers as needed.
Oversees the over-read process of HEDIS clinical data for all lines of business as conducted by nursing staff.
Master’s Degree in Nursing, Public Health, Business or other related field preferred
Bachelor of Science Degree in Nursing or related healthcare field required
Minimum ten (10) years of experience in healthcare/health plan required
Minimum (3) years of prior management experience required
Minimum (3) years of direct applicable experience with NCQA, URAC and/or Joint Commission standards required
Current Registered Nurse License in the State of Ohio preferred
CPHQor other certification in healthcare management within 18 months of hire required
Demonstrated experience in leading and facilitating cross-functional teams
Demonstrated experience in developing detailed written policies and procedures
Experience in gathering and analyzing health data and drawing conclusions
Experience in applying scalable, disciplined and coordinated operational and technological approaches to improve health care quality and member experience and reduce costs of care
Knowledge of HEDIS
Continuous quality improvement/business process improvement
Excellent demonstration of flexibility and change leadership
Experience aligning resources to operational needs
Excellent analytical and project management skills
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate course of action
Excellent skills in organizational dynamics and ability to work with all levels of leadership including executive level and physician leadership
Able to manage multiple priorities and meet tight deadlines
Excellent written and verbal communication skills including presentation skills
Proficient in Microsoft suite of products including Word, Excel and PowerPoint
Medical Mutual is the oldest and largest health insurer in Ohio. Our headquarters are here and we have offices throughout the state. For 80 years, we've been serving our members and the Ohio communities where they live and work. We strive to be the health insurance choice of Ohioans and help make Ohio the best it can be.