The Director of Quality Management is responsible for the day-to-day implementation, evaluation and continuous improvement of Partners Health Plan, Inc.’s, (PHP) quality assessment and performance improvement (QAPI) program. The Director of Quality Management monitors all related quality and reporting activities such as HEDIS, QARR, and other performance measures to ensure performance meets or exceeds pre-established benchmarks. This position is responsible for working with and coordinating care coordination activities to promote improvement or to remedy quality of care concerns. This position works closely with the Chief Medical Officer and contracted vendors regarding all clinical and reporting matters and is the lead person in the submission of HEDIS and all data integrity audits. The Director of Quality Management follows the Medicare and Medicaid regulations, as well as the Three-Way Contract, in the formulation and execution of PHP’s quality assessment and performance improvement (QAPI) program. The Quality Director is responsible for informing the Board of Directors and Committees of outcome measures, quality improvement concerns and initiatives and for coordinating all Quality Committee activities. This position coordinates all quality measurement, improvement and clinical studies for submission to the State and CMS accordingly.
Duties and Responsibilities:
- Develop a written quality assessment and performance improvement (QAPI) program in consultation with the Chief Medical Officer for PHP Quality Committee’s and Board of Directors’ approval.
- Monitor performance indicators in the QAPI to assess compliance with established performance standards or benchmarks.
- Ensure the QAPI contains the regulatory required quality programs (Chronic Care Improvement Program (CCIP) 42 CFR §422.152(c) and Quality improvement project (QIP) 42 CFR §422.152(d)).
- Oversee the Health Outcome Survey (HOS).
- Oversee the approved Medicare Consumer Assessment of Health Providers and Systems (CAHPS®) vendor to conduct the Medicare CAHPS® satisfaction survey of Medicare and Medicaid enrollees (42 CFR §422.152(b)(5)).
- Oversee the monitoring of the HEDIS measures throughout the year and institute interventions (for those participants who have not yet accessed preventative or other indicated care) to improve these measures before required regulatory uploads.
- Manage the review and submission of the HEDIS roadmap.
- Oversee and manage the HEDIS responsibilities with the auditor.
- Provide oversight and quality assurance functions of the HEDIS software vendor.
- Provide direct oversight of vendors performing medical record chart retrieval and record extraction.
- Monitor all metrics (i.e. charts requested, charts in process; charts pending, current rates) on a weekly basis.
- Work with in-network providers to effectuate more favorable performance results (through their interactions with participants) and to get in-network provider participation in quality initiatives (42 CFR §422.152(a)(3)).
- Implement a program review process for formal evaluation of the impact and effectiveness of the QI Program on a quarterly basis for presentation to PHP’s Quality Committees and Board of Directors. Also implement an annual program review process as required by regulations (42 CFR §422.152(f)(2)).
- Work with the Operations and Care Coordination Departments to implement corrections to problems that are identified through internal surveillance, complaints or other mechanisms (42 CFR §422.152(f)(3)).
- Report and respond to regulatory surveys, audits, and data requirements.
- Participate in CMS, SDOH or OPWDD quality improvement groups and recommend measures and metrics relevant to PHP’s participants with Intellectual and Developmental Disabilities.
- Coordinate and handle the medical record review via approved CMS sampling methodologies for PHP’s providers who are in their recredentialling cycle.
- Investigate and/or coordinate the investigation, as well as the resolution of, quality of care complaints
- Oversee any necessary medical record review to substantiate or supplement encounter reporting.
- Oversee PHP’s TPA regarding the Disease Management Program for participants of the FIDA-IDD and Medicaid only program.
- Handle other metrics and measures as determined by PHP’s Quality Committees and Board of Directors.
- All other duties as assigned.
- Bachelor’s Degree required. Master’s degree in Nursing or Healthcare Administration or Public Health preferred.
- Six years of experience in a health care organization and relevant experience in areas of health care quality, utilization management or patient care required.
- Experience leading or performing HEDIS, CAHPS and Medicare STARS program improvement activities required.
- Certified Professional in Healthcare Quality (CPHQ) certification, preferred.
- Familiarity and understanding of healthcare laws (State and Federal), regulations and standards applicable to a managed care organization required.
- Excellent organizational skills and attention to detail required.
- Effective verbal, written and interpersonal communication skills required.
- Excellent documentation, analytical and problem-solving skills required.
- Excellent working knowledge of Microsoft Word, Excel, Access, and PowerPoint required. Knowledge of other software applications preferred.
- Candidate must possess ability to achieve results in a collaborative, executive management environment.
Requirements of All Positions:
- All employees shall meet PHP’s Compliance and Privacy Regulations, and attend at a minimum of one (1) hour of Compliance and Privacy educational training annually;
- All employees shall master PHP’s Model of Care and complete all training requirements within the first thirty (30) days of employment and annually thereafter, or as required by state and federal regulations;
- All employees are required to maintain confidentiality, protect privacy, comply with Protected Health Information regulations, and report violations;
- Perform functions as they relate to “Improving Health Care Quality” as defined in the National Association of Insurance Commissioners Supplemental Health Care Exhibit that:
1. Improve health outcomes;
2. Prevent hospital readmission;
3. Improve patient safety and reduce medical errors, and
4. Provide wellness and health promotion activities.
Physical Demands and Work Environment:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel utilize objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl.
The employee must occasionally lift and/or move up to 25 pounds, and infrequently up to 50 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus. The noise level in the work environment is usually moderate.
Equal Opportunity Employer