Clover is reinventing health insurance by working to keep people healthier.
The Clinical Quality Programs Team is responsible for monitoring the quality of care our members receive & ensuring the effectiveness of our programs & initiatives -- implementing best practices & processes to enhance our clinical operations & business efficiency.
As the Manager, Clinical Quality Programs (Regulatory), you will support our Clinical Quality Programs by leading a high performing team & executing on organizational quality improvement programs as dictated by CMS Medicare Managed Care Manual Chapter 5 requirements, as well as implementing internal Quality Improvement monitoring & activities to support our annual Work Plan.
You will have a strong understanding of improving business processes across the Clover organization & with external partners to embed quality into the very fiber of Clover. This role will drive execution of & the ability to recommend process redesign as needed to support CMS MMCM Chapter 5 & other key Clinical Quality Programs such as Quality of Care investigations, Health Risk Assessments, etc. Common objectives will be to maintain high quality, member-centered service delivery, to ensure the business remains compliant with state & federal regulations. This position will also have a key role in collaborating cross-functionally with internal & external stakeholders representing various Clover verticals & functional departments to achieve common organizational objectives using rapid cycle process improvement.
As a Manager, Clinical Quality Programs (Regulatory), you will:
- Execute on compliance & development of regulatory requirements for the Quality Improvement Program core functions & documentation, such as the Annual Quality Improvement Program Description & Annual Quality Improvement Work Plan.
- Partner with Legal & Compliance experts to ensure regulatory compliance on quality initiatives.
- Conduct evaluations of initiative effectiveness on impacting Star Rating performance over time.
- Identify & prioritize actions needed to improve performance & execute function/area objectives that support continuous improvement.
- Collaborate with accountable teams toward progression on the Star Rating work plan.
- Report performance to plan leaders, & escalate issues & barriers to leadership.
- Provide comprehensive analysis of measures, barriers, & opportunities & present results of improvement efforts & ongoing performance measures to senior management.
- Ensure compliance for all quality audits (including CMS Audit readiness for MMCM Ch 5) & maintain all data & process controls.
- Develop & implement with accountable teams to improve measure level performances.
- Demonstrate ability to establish workflows, manage multiple projects, & meet necessary deadlines.
- Directly supervise exempt & non-exempt staff in accordance with company policies & applicable Federal & State Laws
- Apply other related skills and/or abilities required to perform this job.
- Demonstrate ability to effectively exchange information, in verbal or written form, by sharing ideas, reporting facts & other information, responding to questions, & employing active listening techniques.
- Develop/update clinical quality improvement policy/procedures documentation, work instructions & other tools to support execution of Clinical Quality Improvement program & goals.
- Organize cross-functional groups across departments to work collaboratively toward the effective & efficient pursuit of pre-determined goals.
- Manage completion of HEDIS Audit roadmap & other audit deliverables.
- Manage mitigation of internal HEDIS, HOS, CAHPS, & Health Risk Assessment identified risks.
- Support full life cycle process/projects of QI initiatives of Stars program including HEDIS (e.g. medical record chart chase, claims investigation, overread/abstraction, etc.) CAHPS, HOS.
- Ensure that the Chronic Care Improvement Program initiative meets CMS requirements.
You will love this job if:
- You embrace change & have a proven track record of process redesign.
- You have a positive, energetic and optimistic attitude, with a willingness to proactively roll up your sleeves.
- You have a strong ability to bring cross-functional teams together to collaborate & build consensus for strong organizational solutions.
- You are highly detailed & great at prioritizing and executing multiple tasks that adhere to strict deadlines in a fast-paced, changing environment.
- You are passionate in identifying ways to solve complex problems to improve care so that every members life is improved.
- You have a critical & analytical mindset. You understand how all the components of a process fit together & believe in the value of making data-driven decisions; you continuously monitor the efficacy of your program through metrics tracking.
- You are an innovative thinker & use design thinking to develop strategies that work to improve the life of every Clover member.
- You love building consensus and thrive in a continuous value improvement environment.
- You are a strong problem-solver, you like to use your analytical skills to come up with solutions to problems.
- You are collaborative & enjoy working cross-functionally in a matrixed environment to accomplish goals together.
- You are extremely organized & never let things fall through the cracks.
- You are nimble, & comfortable working in a constantly evolving environment. You embrace ambiguity & speed while maintaining a bias towards action.
- You are a motivated self-starter who is comfortable working both independently & as a member of a cross-functional team.
- You have excellent written and oral communications skills, including the ability to work collaboratively & build strong relationships across the organization.
- You are humble & understand that as a manager of people, you are there to serve & support others while working together.
You should get in touch if:
- You have a Bachelors degree in a related field. Masters degree in a related field preferred. Relevant combination of education & experience may be considered in lieu of degree.
- You have active & unrestricted state licensure of RN, PA, NP degree (or similar degree/licensure with the ability to provide clinical oversight of RNs) from accredited program (required).
- You have at least 3 years of Medicare Advantage experience.
- You have expert knowledge of CMS regulatory requirements & program compliance in regards to MMCM Chapter 5.
- You have experience with CMS audit readiness or equivalent.
- You have at least three years experience of progressive responsibility in directly supervising & managing a high performing team (exempt & non-exempt).
- You have excellent analytical, organizational, planning, verbal, & written communication skills.
- You have the ability to write routine reports & correspondence while applying common sense to carry out instructions furnished in written, oral, or diagram form.
- You have strong verbal & written communication & interpersonal skills with the ability to convey complicated information in a digestible form to all levels of the organization. You are as comfortable speaking with your peers as you are with a C-Suite executive.
- You have advanced knowledge of Microsoft & Google Suites.
- You have the ability to create & comprehend reports & spreadsheets.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest & conviction records. We are an E-Verify company.
About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software & analytics to empower our clinical staff to intervene & provide personalized care to the people who need it most.
We always put our members first, & our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate & mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.
From Clovers inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer & our employees are people with different strengths, experiences & backgrounds, who share a passion for improving people's lives. Diversity not only includes race & gender identity, but also age, disability status, veteran status, sexual orientation, religion & many other parts of ones identity. All of our employees points of view are key to our success, & inclusion is everyone's responsibility.