The Clinical Quality Programs Team is responsible for monitoring the quality of care our members receive & ensuring the effectiveness of our programs & initiatives. One of the teams responsibilities is measuring performance on important ranges of care & service through the Healthcare Effectiveness Data & Information Set (HEDIS) tool.
The Manager, Clinical Quality Programs (HEDIS) role will oversee the HEDIS process throughout the year, ensuring HEDIS data accuracy & reporting, including investigations, auditing, & improvement opportunities. In this role, you'll execute & develop Stars HEDIS Strategy with Clinical Quality Program Leadership in partnership with key internal & external stakeholders. You will develop a plan, calendar of initiatives, dive into root cause analysis to address & remove barriers to success. This role collaborates closely with operations, data science, external partners & technology to ensure the HEDIS strategy is implemented & executed leading to improved performance with clinical Stars measures. Through partnerships with key peers, you'll also ensure the organization is increasingly performing across the HEDIS domain. You will also develop key insights & strategy from member & provider strata, geospatial relationships & health inequities.
In this role, you will work closely with internal & external stakeholders while applying both business knowledge & technical expertise to achieve key organizational objectives, support business initiatives & to solve complex population & business problems. You will manage & support a high performing team to ensure the HEDIS lifecycle process runs successfully; & have the ability to identify ways to streamline & improve existing workflows. Common objectives will be to research, compile, & analyze appropriate & relevant clinical quality data to identify opportunities to recommend & execute process efficiencies in assigned business units to achieve targeted levels of improvement in key operational HEDIS performance while maintaining high quality, member-centered service delivery.
As an Manager, Clinical Quality Programs (HEDIS), you will:
- Collaborate with the Head of Clinical Quality Programs & key stakeholders on strategic initiatives, key performance indicators & domain drivers.
- Execute & develop Stars HEDIS strategy based on your analysis of insights, best practices & utilization of innovation & design thinking practices.
- Serve as HEDIS clinical subject matter expert in supporting measure improvement initiative design, annual audit & MRR project across multiple clients.
- Be responsible for leading clinical HEDIS communications with internal & external partners demonstrating expertise in technical specifications & application in clinical settings
- Collaborate with internal & external stakeholders to ensure HEDIS initiatives are fully integrated throughout the organization, maximizing opportunity to improve outcomes for members
- Apply knowledge of HEDIS technical specifications, NCQA audit requirements, MRR project oversight, HEDIS quality measures to ensure Stars technical guidance from CMS, NCQA, & internal/external teams are incorporated into the work plan
- Take lead on Stars HEDIS request for information & collect & consolidate measure owner feedback
- Provide effective & efficient solutions to complex business problems by integrating analytics to inform initiatives & reporting
- 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
- Formulate & ensure compliance with HEDIS technical specifications, policies, operating procedures, & goals in compliance with internal & external guidelines
- Provide comprehensive analysis of HEDIS measures, barriers, & opportunities & present results of improvement efforts & ongoing performance measures to senior management
- Oversee HEDIS projects to include assignment of nurses, adherence to plan timelines, & RN overread/abstraction oversight for timeliness & quality
- Ensure compliance for all quality audits & maintain all data & process controls
- Develop & implement with accountable teams to improve measure level performances
- Demonstrate ability to effectively present budgetary and/or cost information, & respond to questions as appropriate
- 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
You will love this job if:
- 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 programs through metrics tracking
- You are a strong problem-solver, you like to use your analytical skills to come up with solutions to problems
- 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 are humble & know that as a manager of people, you are there to serve & support others while working as a team
You should get in touch if:
- 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 deep experience (at least 3-5 years) of MAPD Star Ratings focusing on HEDIS strategy experience working on related programs
- You have strong operational expertise in the NCQA HEDIS including technical specifications including HEDIS audit lifecycle & completion of key audit deliverables such as MRRV & HEDIS roadmap
- You have at least three years experience of progressive responsibility in directly supervising & managing a high performing team (exempt & non-exempt)
- 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 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 an executive
- You have advanced knowledge of Microsoft & Google Suites, & the ability to create & comprehend reports & spreadsheets in Excel
- You have working knowledge of SQL (preferred)
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.