|Job Location: Portland, ME
Requisition #: 2015-228
# of openings: 1
The Manager Quality Programs in conjunction with the Medical Director oversees the health plan quality improvement initiatives to ensure alignment with the overall strategic plan and accurately reflected internally and externally in quality description presentations, documents and work plans. The Manager Quality Programs oversees ongoing quality improvement initiatives, including initiatives that develop from HEDIS and NCQA activities, to ensure success for accreditation, quality improvement activities, performance improvement projects, committee actions, customer satisfaction, and a variety of other health plan initiatives. This role is responsible for analyzing and proposing strategies to the Medical Director to meet the organization’s compliance with accreditation standards and continual accreditation readiness, oversees and champions work related to the organization’s Triple Aim (Improving patient experience, population health and cost of health care), and communicates and shares best practices in quality improvement across the organization and externally. Effective collaboration with leaders across the Martin’s Point organization is critical to the success of these efforts.
- Facilitates and compiles results of the organization’s quality improvement activities and annual plans in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, terms of government contracts (e.g., Department of Defense, Medicare) and accreditation standards.
- Monitors and evaluates member care and services to ensure that care provided by Martin’s Point Health Care meets or exceeds the requirements of good medical practice; is positively perceived by Martin’s Point Health Care members, patients and health care professionals; and meets accreditation & DoD requirements and reports progress or lack thereof related to the QI workplan .
- Develops and implements systems, policies, and procedures for the identification, collection and analysis of performance measurement data, and special projects.
- Facilitates the business areas focus on QI workplan and reports on their pogress or lack there of around the systems, policies, and procedures to support proactive and retrospective quality assessment of the care provided by network providers, including routine medical record audits; tracking and follow up of incidents, accidents, and occurrences; peer review; root cause analysis and process improvement to continually improve the care we provide.
- Educates and trains the leadership, staff and business associates as to quality improvement work plan activities, and their respective responsibilities in carrying out the activities, and continuously seeks and shares quality improvement best practices.
- Serves as support to the Medical Director in reporting to the Health plan quality management committee (HPQMC) and the Clinical Quality Leadership Committee (CQLC) on progress related to QI work plan activities, quality improvement initiatives, opportunities for improvement.
- Leads, facilitates and advises internal quality improvement teams related to the overall quality work plan.
- Collects and summarizes performance data, identifies opportunities for improvement, facilitates clinical performance improvement projects, and presents findings to appropriate committees and external organizations
- Oversees the accreditation processes to ensure MPHC maintains continuous readiness for accreditation.
- Acts as a subject matter expert on quality improvement analysis of data to ensure excellent performance, including establishing data-driven performance expectations, providing timely, constructive performance feedback and coaching, and coordinating or conducting training to support staff to develop the necessary skills to perform their job functions to quality improvement goals.
- Facilitates and oversee in conjunction with the manager of benefit review-the review and reporting of potential quality of care issues. Facilitate the collection of relevant data and analyze for trends for reporting to the appropriate committees of quality of care incidents, corrective actions, and patient safety improvements. Prepare reports and facilitate the peer review process in collaboration with the Medical Director as well as the tracking and follow up of incidents, accidents, and occurrences; root cause analysis and process improvement to continually improve care.
- Facilitates and report on the development and update of clinical UM guidelines, clinical practice guidelines and medical policies as well as departmental policies and procedures as appropriate in conjunction with the health plan medical director to internal and external customers to ensure appropriate standards of care are consistently utilized as they align with the QI workplan activities and initiatives.
- Collaborates and present to clinical committee updates to medical policies and clinical UM guidelines as appropriate.
- Develops and implements annual operating plan and budget in conjunction with the medical director to ensure goals are met.
- Supports the HEDIS data collection process to ensure the validity of the data collection process and ensure accurate reporting to meet five star and accreditation goals.
- Oversees and facilitate the accreditation survey requirements and satisfaction analysis such as the member behavioral health survey and report results and opportunities related to the QI workplan activities.
- Collaborates and develop internal and external relationships to promote quality programs and the strategic vision for MPHC, External partners may include account relationships (Alliance committees and military committees) as well as ad hoc quality committees for DHA and CMS as appropriate as well as vendors and providers to ensure quality goals are met.
- Collaborates and report quality of care and updates to guidelines with credentials and policy committee to maintain the quality of network providers
- Continually improves department processes and services.
- Participates in external professional organizations and committees.
- Clinical degree (RN, NP, PA, etc.) and Bachelors Degree required. Masters degree in a related field preferred.
- 10+ years experience in a health care related organization.
- 5+ years experience in a managed care setting, with experience leading accreditation and quality management process improvement efforts.
- 5+ years leadership experience; including managing cross-functional teams and influencing cross functional areas without direct authority.
- Experience with managed government programs including Medicare Advantage preferred.
- Demonstrated application of statistics, data collection, analysis and data presentation.
- Knowledge of federal and state laws and regulations and applicable accreditation standards.
- Demonstrates an understanding of and alignment with Martin’s Point Values.
- Excellent interpersonal communication and problem solving skills.
- Excellent customer service focus: Team oriented individual with a high level of interpersonal skills, upbeat personality, and the ability to relate to all internal and external customers in a positive and professional manner.
- Strong track record of building internal and external collaborative relationship.
- Demonstrated expertise with the fundamentals of Quality Management and Process Improvement is required.
- Computer skills including Microsoft Word, Access, Excel, Visio, Outlook, and Internet.
- Proven history of being an effective team leader and team builder.
- Demonstrated ability and desire to coach employees and develop staff through training, stretch assignments and constructive feedback.
- Fair and Flexible, High Ethical Standards.
- Good at delegation of responsibility and establishing accountability.
- Able to set appropriate measureable targets and get results.
- Able to design work processes around customer needs and expectations, measure results, and improve systems when target not met.
- Applies proactive and innovative solutions to improve process effectiveness.