Prgm Coord-Qlty Medicare Adv - 3553

Hours

Shift Start Time:

8 AM

Shift End Time:

4:30 PM

Additional Shift Information:

Weekend Requirements:

No Weekends

On-Call Required:

No

What You Will Do
In collaboration with the SHP medical directors and QI manager, this position will provide oversight for Sharp Health Plan's improvement strategies related to population health and performance metrics for the Medicare Advantage product. The position coordinates the implementation and maintenance of strategic programs designed to improve clinical outcomes through the provision of clinical information and education materials to both providers of care and to members. The position acts as a key lead in the team responsible for the measurable improvements in ambulatory clinical quality and population health management that provide value to the health plan resulting in a strong business case for improved clinical outcomes and meeting CMS requirements. The position will attain and maintain a thorough understanding of SHP's technical capabilities. The position will be responsible for implementation and coordination of all tasks and strategies for SHP's required reporting initiatives to HPMS. Design, implement, and lead analytical processes and reporting metrics for the Medicare Stars process improvement program. Collaborate with other across the Sharp system and Plan delegates including the PBM to support QI strategies for MA Stars programs. Implementation of special initiative to support the analytical and reporting needs of the QI department and its delegates for CMS programs working closely with the Pharmacy Benefits department to collaborate on quality improvement initiatives. Provides coordination with Plan medical groups to gather required contractual data in conjunction with the Compliance department for CMS audits. Supports both long term and short term projects, which require organization, research, analysis, planning, development, modeling, validating, and/or coordination such as written QI studies required by CMS. Serves as point person for reporting, research, analysis, and coordination for QI department for CMS required programs. Perform all other duties as assigned.

Required Qualifications

• 10 Years Experience in position requiring high levels of cooperation, collaboration, analysis, troubleshooting, and problem resolution in the healthcare industry
• 10 Years Experience managing complex CMS programs including health care systems and software.
• Experience in the successful design, implementation, and completion of interdepartmental project management

Preferred Qualifications

• Bachelor's Degree Health care field
• Master's Degree Heath care administration, public health, business or related field
• California Registered Nurse (RN) - CA Board of Registered Nursing -PREFERRED

Other Qualification Requirements

• Certification in Project Management preferred

Essential Functions

• Completes other duties as assigned
  Participates in special projects and other duties as assigned.
  These may include, but are not limited to, work groups, proposals, audits, and back up support for other departments.
• Performance Improvement
  Implements population health strategies and improvement of performance metrics for the Medicare Advantage product.
  Manages the implementation and maintenance of strategic programs designed to improve clinical outcomes through the provision or clinical information and educational materials to both providers and members.
• Process improvement
  Designs, implements, and leads analytical processes and teams responsible for reporting metrics for the Medicare Stars process improvement program.
  Collaborates with clinical leadership across the Sharp system and Plan delegates including the PBM to support QI strategies for MA Stars programs.
• Program management
  Responsible for CMS required Quality Improvement (QI) programs as stipulated in the SHP QI Program Description.
  Responsible for all HPMS system entries for QI programs including submission of required QI studies.
  Coordinates data and reports for chronic care improvement programs per CMS requirements.
• Provides internal and external customer service
  Provides prompt, accurate, and excellent service to internal and external customers.
  Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers, and/or customers.
• Quality and service
  Develops and manages projects for the QI department to support quality and service improvement initiative.
  Supports CMS audit processes in partnership with Compliance department and Health Services UM department.

Knowledge, Skills, and Abilities

• Knowledge and experience in health plans or physician organizations with Medicare Advantage populations including familiarity with quality improvement, utilization management, and disease management.
• Knowledge of CMS, NCQA, HEDIS, P4P, Medicare Stars and other performance metrics.
• Experience with population health management and health information management; knowledgeable about compliance and reporting initiative; proven ability to manage performance improvement projects.
• Excellent verbal and written communication skills; strong interpersonal skills.
• Strong ability to read and interpret documents addressing performance incentive programs, program specification, etc.
• Ability to manage multiple projects and priorities.
• Skill in working across departmental lines .
• Ability to work independently and effectively with physicians, SHP staff, health, contracted medical groups, and various members of the health care team across SHC.
• Knowledge of available community resources and current standards of clinical practice.
• Knowledge of managed care, Health Plan contracts, and benefits. Understanding of ICD and CPT coding.
• Strong computer skills.
• Strong organizational skills.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class