This job focuses on ensuring enterprise-wide compliance with clinical and service quality requirements for mandatory quality accreditation, federal, and Center for Medicare and Medicaid Services (CMS) regulations. Leads professional consultant 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 the Organization is compliant with all applicable external accrediting and regulatory requirements (NCQA, CMS, DOH, URAC, etc.), as applicable in all service regions. The incumbent's responsibilities include, but are not limited to, the QI program achieving enterprise related Star goals for all Medicare lines of business, supporting a positive Accreditation status (as applicable), and ensure timely compliance to all quality reporting required by CMS to monitor plan performance. The incumbent leads 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), URAC Health Utilization Management, Centers for Medicare and Medicaid Services (for Medicare Advantage). Leads professional staff in ensuring corporate compliance with member services and provider accessibility requirements, member and practitioner/ practice adherence patterns and compliance activities for all regions of operation to identify barriers that are unique to each area and to direct the development of specific targeted interventions to ensure continued improvement of clinical and service quality. Leads the consultant team to identify and address regulatory and compliance risk throughout the Organization's departments across its service regions. This job requires strong on-going knowledge of the dynamic external accrediting and regulatory requirements and compliance with intricate and detailed specifications.
- Direct 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 Medicare markets and all associated Organization health insurance products that impact Organizational compliance with regulatory and accreditation requirements for health plans.
- Achieve Organization goals set for CMS Stars program metrics, support maintaining a positive Accreditation status (as applicable), and ensure all quality reports to CMS regarding performance outcomes for covered lives are accurate, timely, and complete.
- Direct professionals who lead multidisciplinary groups of individuals throughout the enterprise to develop interventions and direct provider-based and internal Organization 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. These activities impact the Organization's market standing and sales efforts and include the corporate expectation of continual improvement the Organization's ratings across all lines of business and in all service regions.
- Direct professional team members in their advisory roles to departments across the Organization 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 Organization service area to improve care/service. Lead and direct areas within QMPM to develop the knowledge used to drive changes.
- Direct and lead professional staff in the development, adoption, and continued maintenance of nationally-endorsed preventive health and clinical practice guidelines that are utilized by the Organization's network providers as guidance for providing care to their patients who are the Organization's members. Additionally, the preventive health guidelines form the basis for the corporate-wide Organization preventive health schedule of benefit coverage for members and apply to all applicable Organization health insurance products across all Organizational 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 Law Department. Represents the Organization's interests with national organizations and national projects to develop and implement such guidelines. Responsible for maintaining information and company history regarding guideline decisions.
- Direct and lead 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 implementation of interventions.
- Maintain information and health plan history regarding the analysis and ongoing activities in place to meet compliance. Applies to Medicare markets. Impacts the Organization's compliance with NCQA, and Pennslvania CMS as applicable.
- Direct and lead 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 Medicare markets. Impacts the Organization's compliance with NCQA, Federal and CMS requirements.
- Direct and lead professional staff that ensures member intervention and satisfaction/dissatisfaction activities are completed timely, including overseeing administration of member and provider incentive activities, 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 the Organization 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 all Medicare markets.
- Direct and lead professional staff that ensures compliance with the Blue Cross Blue Shield Association (BCBSA) transparency initiatives on Blue Physician Recognition and Physician Quality Measurement. Compliance with these BCBSA mandates impacts the Organization's relationship with its licensing entity and avoids substantial financial penalties for the corporation that would be levied if the Organization fails to comply with the mandates.
- Other duties as assigned or requested.
- Bachelor's Degree in Nursing, Business or Public Health FIeld
- Master's Degree in Business Administration or Health related field
- 5 years with continuous Quality Improvement processes including Project Planning and managing multiple priorities
- 5 years interpreting regulations and assessing plan impact, implementing processes to enhance compliance and auditing results
- 5 years in Leadership
- 3 years working in an Outpatient Clinical setting
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.
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