Manager, HEDIS & Accreditation
The Quality Accreditation Manager is responsible for the overall management, strategic planning and maintenance of NCQA accreditation and HEDIS performance and reporting. Management includes the development and monitoring of a comprehensive accreditation program including HEDIS and NCQA activities, a detailed project plan linked with accreditation standards, required quality studies, prioritized interventions and on-going monitoring for compliance with standards and contractual accreditation requirements and reporting to senior management. The accreditation manager works with senior management, various departments including medical management, network and operational staff in leading and managing all aspects of the accreditation process. Also coordinates activities with Subject Matter Experts, business owners, vendors and network providers to accomplish accurate and timely HEDIS reporting and to implement improvement activities. Also assists with internal audits to determine compliance with NCQA standards and state regulatory standards. Is also responsible for document retrieval and submission for DHCS and DMHC audits. Work is varied and moderately complex, and requires a moderate degree of discretion and independent judgment.
NCQA and HEDIS coordinators.
Develop multidisciplinary training and education programs for staff, providers, and members regarding HEDIS, CAHPS and NCQA. Develop and manage on-going audit activities to ensure accreditation compliance.
Collaborate with the Directors and the Managers of other departments to ensure compliance with the NCQA standards for accreditation and HEDIS reporting.
Ensure maintenance of NCQA document library.
Ensure timely and accurate submission of the NCQA documents.
Manage the HEDIS performance and reporting, meeting contractual requirements and NCQA accreditation requirements.
Maintain all vendor and consultant relationships related to NCQA and HEDIS.
Coordinate all activities related to HEDIS reporting including development of the road map, maintaining the relationship and interaction with the vendor and auditors, leading the audits, medical record collection and abstraction and submission of the final reports.
Develop and oversee the successful implementation of provider and member interventions such as distribution of provider report cards and development and implementation of member incentives.
Ensure completion and analysis of all NCQA and regulatory required surveys and reports to the appropriate Quality Committees.
Coordinate member and provider input as needed for accreditation and HEDIS.
Maintain a document library with all NCQA and HEDIS related documents.
Promotes and maintains, and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values.
Hires, supervises and retains, and ensures that line staff hire supervise and retain, a competent staff.
Knowledge of the health care industry especially the managed care industry and its products and services.
In depth knowledge of Quality Management principles and practices.
Knowledge of HEDIS reporting and improvement process.
Knowledge of NCQA accreditation.
Ability to conduct data analysis.
Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.
Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
Decision quality: Makes good and timely decisions that keep the organization moving forward.
Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.
Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.
Ensures accountability: Holds self and others accountable to meet commitments.
Drives results: Consistently achieves results, even under tough circumstances.
Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of HPSJ.
Strong oral and written communication skills, including the ability to communicate professionally and effectively with individuals and groups inside and outside of HPSJ.
Persuades: Uses compelling arguments to gain the support and commitment of others.
Collaborates: Builds partnerships and works collaboratively with others to meet shared objectives.
Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.
Being Resilient: Rebounds from setbacks and adversity when facing difficult situations.
Strong knowledge of change management theory, with the ability to implement effectively.
Strong project management skills and demonstrated ability to lead complex initiatives.
Strong customer service skills.
Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
Strong management skills, including but not limited to the ability to supervise staff in a manner that maximizes employee performance and business results.
Proficient in Microsoft Office suite.
Ability to handle confidential information with appropriate discretion.
Previous health plan experience.
BS degree in business management or other relevant disciplines; and
At least three years of progressive experience in Quality Improvement especially with HEDIS and NCQA activities; and
Demonstrated ability to manage projects through influence and across cross functional teams; and
At least two years of supervisory experience; and
Managed Care experience.
Medicaid Managed Care experience.
Previous leadership experience with HEDIS and NCQA accreditation