Director Clinical Services & Quality (HEDIS)

Job ID: J115853
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 11, 2018

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Description

I.    GENERAL OVERVIEW:  
The job will focus on ensuring enterprise-wide compliance with clinical and service quality requirements for mandatory quality accreditation and federal and multi-state regulations.  Primary responsibility is to directly lead, professional staff in the development, implementation and on-going monitoring and follow through for the health plan’s clinical and service quality programs and initiatives to ensure Gateway is compliant with all applicable external accrediting and regulatory requirements (NCQA, CMS, DOH, URAC, etc.), as applicable in all service regions.  This includes leading a team of clinical and non-clinical professionals to work with various departments across the corporation  and to direct multidisciplinary quality committees comprised of internal staff and/or external network providers to ensure interventions are fully developed and implemented to complete the annual requirements for the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (for Medicare Advantage), Pennsylvania Department of Health and Department of Insurance for the CHIP Product.  

Will lead the team to successfully monitor, report, and address issues related to Health Care Effectiveness and Data Information Set (HEDIS) as well as oversee and direct activities required for HEDIS submission to NCQA, including but not limited to chart retrieval and abstraction for hybrid data collection and reporting.  The Director will lead the team to identify and address regulatory and compliance risk throughout Gateway departments across its service regions.  The position requires strong on-going knowledge of the dynamic external accrediting and regulatory requirements and compliance with intricate and detailed HEDIS specifications.


II.    ESSENTIAL RESPONSIBILITIES:  


1.    Directs and is accountable for professional staff, both clinical and nonclinical, which is responsible for ensuring clinical and service-related compliance of the corporation.  This includes quantitative and qualitative analysis to identify improvement opportunities and implementing interventions to improve member care and service.  


•    Activities apply to the Delaware, Pennsylvania and West Virginia markets and impact Gateway compliance with regulatory and accreditation requirements for health plans.


2.    Directs and is accountable for professionals who lead multidisciplinary groups of individuals throughout the enterprise to develop interventions and direct provider-based and internal Gateway committees to advance member health and service outcomes.  This involves action plan development, timelines, large-scale complex multi-pronged interventions, and communication strategies for complex issues with large impact on the organization and its members.  


3.    Directs the professional team members in their advisory roles to departments across the corporation in order to revise and enhance enterprise-wide interventions to affect positive changes in Health Plan customer service and member health care.  This requires up-to-date knowledge of current and upcoming trends in health and customer service opportunities and the ability to correctly identify root cause barriers and develop cost-effective interventions across the Gateway service area to improve care/service. 


4.    Directs and leads professional staff in the development, adoption, and continued maintenance of nationally-endorsed preventive health and clinical practice guidelines that are utilized by Gateway network providers as guidance for providing care to their patients who are Gateway members.   Additionally, the preventive health guidelines form the basis for the corporate-wide Gateway preventive health schedule of benefit coverage for members and apply to all applicable products across all Gateway service regions.  The ongoing guideline process requires frequent interaction by the professional staff with various corporate representation at the manager and director levels, including, but not limited to: benefits coding, sales, product, actuary, utilization management, and the legal department.  Represents Gateway interests with national organizations to develop and implement such guidelines. Responsible for maintaining information and company history regarding guideline decisions.


5.    Directs and leads professional staff that ensures corporate compliance with accreditation and regulatory standards for continuity and coordination of medical care and behavioral health care activities.  This includes development and implementation of clinical research, analysis, identification of improvement opportunities and ensuring interventions are implemented. Responsible for maintaining information and corporate history regarding the analysis and ongoing activities in place to meet compliance.


•    Applies to Delaware, Pennsylvania and West Virginia markets.  Impacts Gateway’s compliance with NCQA, Medicare Advantage, Pennsylvania Department of Health, West Virginia Insurance Commissioner’s Office and Delaware Insurance Department requirements.


6.    Directs and leads professional staff that maintains accessibility activities to ensure members have appropriate and timely access to care and services across all health insurance products.  This includes development and implementation of research, analysis, identification of improvement opportunities and implementation of interventions. 


•    Applies to Delaware, Pennsylvania and West Virginia markets.  Impacts Gateway’s compliance with NCQA, Medicare Advantage, Pennsylvania Department of Health, West Virginia Insurance Commissioner’s Office and Delaware Insurance Department requirements.


7.    Directs and leads professional staff that ensures member satisfaction/dissatisfaction activities, including overseeing administration of the annual CAHPS® member satisfaction and Behavioral Health satisfaction surveys conducted through an NCQA-certified external vendor, including selection of the vendor, contract execution and administration. Activities includes development and implementation of studies/data collection, monitoring of enterprise-wide satisfaction/dissatisfaction data, identification of improvement opportunities and coordination with departments throughout Gateway for implementation of interventions that are corporate-wide in nature and affect multiple departments. Additional responsibilities of the staff include accountability for coordination of activities with Healthcare Management Services, performance report analysis, annual compliance audits, and documentation maintenance. Applies to Delaware, Pennsylvania and West Virginia.


8.    Oversees and directs the monthly and annual HEDIS chart retrieval and abstraction process for annual NCQA submission.  Project manages selected vendors to ensure service level agreements are met or exceeded.


9.    Other duties as assigned or requested.

III. QUALIFICATIONS:
Education, Licenses/Certifications, and Experience 

Minimum
•    Bachelor’s Degree in Nursing or public health field
•    5 years’ experience with continuous quality improvement processes including project planning and managing multiple priorities
•    5 years of experience interpreting regulations and assessing plan impact, implementing processes to enhance compliance, and auditing results.
•    5 of leadership experience  
•    Strong analytic skills and a broad working knowledge of current health insurance accreditation guidelines and applicable government regulations    

Preferred

•    Master’s Degree in Business Administration or health-related field is preferred
•    At least 3 years’ experience working in an outpatient clinical setting
•    3years NCQA and HEDIS experience
•    Current RN license for applicable state


Knowledge, Skills and Abilities  
•    Proven leadership skills – ability to influence and motivate others to achieve results
•    Strong and effective verbal and written communication skills
•    Ability to present complex topics in a concise manner
•    Broad understanding of business issues, metrics, organizational linkages and customer value
•    Excellent analytical skills, with the ability to assess scenarios based on  real-world applications
•    Successful experience in achieving results through people in a complex environment
•    Ability to motivate professional staff to meet strict project and reporting deadlines
•    Strong knowledge of Highmark and its diversified businesses and the on-going company strategy
•    Ability to focus on details, but with an overall understanding of the business
•    Ability to provide sound project direction, interact effectively with senior management and others within the corporation, and facilitate project assessments, present findings, status and recommendations in a professional manner
•    As the activities for which this position is responsible are of critical importance to Highmark, the incumbent must be methodological in problem resolution while considering multiple resources  both inside and outside the company and multiple tasks 
•    Ability to recognize and balance business and operational constraints without jeopardizing compliance


 

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
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