Clinical Reporting, Professional, Quality Initiatives Lead
Status: Full-time, Exempt: Yes
Obtain and analyze monthly data required for NCQA standards, HEDIS/QARR measures and CMS Star quality ratings. Interpret these findings, identify barriers, and propose methods for improvement. Collaborate and communicate with internal departments to implement effective interventions that support NCQA health plan accreditation and the increased performance of HEDIS/QARR/STARS rates. Develop documentation and reporting tools to allow QI to track the progress and success of our outreach and interventions at both the
member and provider level. Perform as an active member of all quality meetings that pertain to increasing quality results. Performs other duties as assigned by management.
Provider Initiatives –
• Develop Provider Incentive programs and collateral, such as Medicaid RQI and Marketplace Incentive.
• Coordinates the distribution of Quality data to our provider community, working collaboratively with Provider relations, Provider Engagement and Networks.
• Develops and implements a system of communications and tracking that ensures all physicians have access to reports.
• Influences provider practice patterns in a positive manner for all lines of business to improve the quality of care and encourage appropriate care to be delivered in the appropriate setting.
Member Initiatives –
• Develop Member Incentive programs and collateral, obtain NYS approval when necessary.
• Coordinate member call campaigns, mailings and incentive programs to support QI outreach and interventions.
• Work collaboratively with Marketing & Communications, Community Engagement and Community Health Promotions to develop opportunities for member education and improving the health of our member community.
Bachelor's degree or equivalent combination of education and experience in a managed care environment.
Minimum of three years health care or managed care experience is required.
Minimum of two years mental health or substance abuse experience is required.
Experience with HEDIS/QARR/STARS.
Experience working within a quality improvement role is strongly preferred.
• Excellent analytical skills are required. Takes action to solve problems and move situations to closure while demonstrating sound judgment and a clear understanding of issues.
• Demonstrated experience with and proficiency in the management of data, reports and database.
• Superior attention to detail and strong project management skills are required. Prioritizes various competing tasks and performs them efficiently according to their urgency.
• Adapts and works effectively with individuals or groups. Works comfortably during changing circumstances. Adapts approach as the requirements of a situation change. Changes or easily accepts changes in job requirements.
• Excellent interpersonal and communication (telephone, verbal and written) skills required.
• High proficiency with Microsoft Office Suite.
• Some travel including periodic overnight stays will be required.
• Experience with Macess, Facets and/or Care Radius is a plus.
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- Job Family Medical Management/Clinical
- Pay Type Salary
- Headquarters Office, Schenectady, New York, United States of America
- Rochester Office, Rochester, New York, United States of America
- Tarrytown Office, Tarrytown, New York, United States of America