Leads the quality assessment, quality program management and quality performance improvement strategies for VNSNY CHOICE Medicaid and Medicare products in collaboration with senior leadership and service delivery management. Works to advance VNSNY CHOICE status as a ‘World Class’ health plan to the community and regulatory agencies. Develops, implements and refines quality and safety programs at the inter-professional level through consultation, program activities and collaboration across VNSNY CHOICE Health Plans. Participates in the development of quality metrics to support performance improvement initiatives and quality/compliance oversight. Serves as quality subject management expert with other stakeholders to drive quality management strategy Builds shared vision to incorporate a culture that is data driven and aligns with evidenced based best practices that are compliant with CMS and NYS DOH requirements. Facilitates and supports operational changes and activities which support quality improvement and clinical staff development goals. Works under general direction.
Responsibilities
Leads the development of the Quality Improvement Program for assigned product lines.Designs, initiates, and leads strategies and projects that foster the application of continuous improvement principles and best practices among Medicare and Medicaid products, in collaboration with senior leadership and service delivery management.Designs and evaluates clinical support and education programs that are integrated with and facilitate quality improvement strategies and achievement of the Enterprise’s strategic objectives.Develops strategic plans and policies for improved quality for all lines of business and works with senior leadership to ensure compliance with regulationsDevelops strategies and methods for the collection, analysis and dissemination of clinical performance data.Serves as a subject matter expert to leadership, internal service delivery management and network providers in the areas of quality assessment and performance improvement initiatives.Evaluates the impact of industry and regulatory changes on the Quality Improvement programs; recommends appropriate and necessary changes. Leads implementation of such changes.Participates with other VNSNY staff in interacting with regulatory, health and community agencies in identifying and influencing public policy issues that relate to the health plans. Represents VNSNY CHOICE internally and externally and increases public awareness of program through education, presentations and marketing of services.Ensures quality initiatives are aligned with CMS Triple Aim framework: improving the member’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.Directs VNSNY CHOICE Quality metrics related to regulatory compliance and performance improvement initiatives.Functions as the Quality liaison for the development of analytic systems and databases that support the development of systems and strategic initiatives as requested by the Enterprise.Develops strategies and methods for collection, analysis and evaluation of the quality improvement projects. Oversees project work plans, including objectives, tasks and time frames to ensure deliverables are completed on time. Identifies and responds to changing project circumstances and communicates issues to leadership as appropriate. Initiates and leads project evaluation process at project close.Keeps informed of the latest internal and external issues and trends in utilization and quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies and procedures to address these trends. Leads annual HEDIS/QARR submissions to ensure validity of data and ability to submit for reporting, including both Medicare and Medicaid submissions and specific requirements for expansion area submissions.Leads HEDIS/QARR Medical Record Review projects which include developing project plans, ensuring adherence to plan timeline, conducting vendor oversight for timeliness and quality of performance, monitoring project progress and providing status update to leadership.Leads implementation of required and off cycle satisfaction surveys for Medicare, Medicaid, and MLTC and HOS survey for Medicare.Designs, monitors, and evaluates performance and project improvement strategies to ensure gains and corrective action, strategic goals, and financial targets for HEDIS/QARR/HOS/CAHPS are met.Works closely with HEDIS/QARR auditors, vendors, internal VNSNY staff, external customers, CMS, NYSDOH, IPRO and other regulatory agencies by leading execution of all mandated HEDIS/QARR/HOS/CAHPS activities and performance improvement projects.Interfaces with VNSNY CHOICE providers and staff as a facilitator, resource, educator, problem-solver and collaborator for HEDIS/QARR/Gaps in care related quality management projects. Collaborates with other departments and staff on project implementation to maximize efficiency and teamwork.Collaborates with operations management in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies. Ensures corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.Performs all duties inherent in a senior managerial role. Ensures effective staff training and evaluates staff performance. Approves staff training, hiring, promotions and terminations and salary actions. Prepares and ensures adherence to the department budget.Participates in special projects and perform other duties as required.
Qualifications
Education: Master’s Degree in Health Care, Nursing, Public Health, Education, Business Administration or related field required.
Experience: Minimum of seven years’ of progressive experience in quality improvement and measurement, health information management, strategic planning, performance improvement, and/or research required. Management experience preferred. Experience in a long term care or with a managed care organization required. Demonstrated ability to lead project teams, develop project plans with corporate wide impact, and work in team groups required. Excellent problem-solving skills required. Strong oral/written communication, presentation, and organizational skills required. Proficiency in training and staff development preferred. Proficiency with personal computers, including Windows, Excel, Word and Power Point required.