Quality Manager

The Quality Manager is responsible for leading key components of the Plan’s Massachusetts (MA) Quality Assessment and Performance Improvement (QAPI) Program including consultation regarding clinical and operational quality improvement initiatives. The Quality Manager is responsible and accountable for clinical quality improvement initiatives which comply with contractual obligations, regulatory requirements and accreditation standards. Provides clinical high-level support for process and operational improvements related to clinical initiatives within the Office of Clinical Affairs.

Key Functions/Responsibilities:

– Ensures the Plan meets contractual, regulatory and accreditation (e.g. EOHHS, EQRO, NCQA, Health Connector, and CMS) requirements for MassHealth Quality
Improvement Goals, External Quality Review Organization (EQRO) performance improvement projects, Qualified Health Plan (QHP) Quality Improvement Strategy
projects, and related initiatives.
– Develops and implements, evaluates and documents interventions related to MassHealth Quality Improvement Goals, MassHealth and Senior Care Options (SCO)
EQRO Performance Improvement Projects, and other quality improvement goals/projects.
– Develops and documents the Quality Improvement Work Plan and Work Plan Evaluation
– Facilitates large multidisciplinary committees and smaller subgroups to create and implement interventions to meet performance improvement project goals.
– Generates supporting documentation for new project proposals, including internal and external reports.
– Ensures that responses to inquiries from MassHealth, EOHHS, and CMS regarding the Quality Improvement Goals and EQRO are timely and complete.
– Responsible for clinical quality related aspects of the SCO Program contract as well as CMS regulatory requirements.
– With SCO leadership ensures organizational preparedness to achieve corporate STAR ratings goal. Reports to SCO Steering committee as appropriate.
– Works collaboratively with the Quality Program Manager to organize and coordinate the MassHealth Quality Goals and EQRO Performance Improvement Projects
including goal design, implementation, tracking, reporting and evaluating overall effectiveness of the initiatives.
– Chairs the Massachusetts Quality Committee, a multidisciplinary group, to ensure progress with addressing all opportunities for improvement in regulatory submissions
as well as HEDIS performance.
– Collaborates with other areas (e.g. Clinical Informatics) to evaluate opportunities for improvement, develop and implement interventions, perform root cause analyses,
and recommend appropriate actions to improve clinical and non-clinical outcomes.
– Serves as liaison with providers, local educational and clinical agencies to support partnership opportunities developed to enhance the services provided to the Plan
members.
– Works with Chief Medical Officer (CMO), Senior Leadership and medical directors to achieve corporate quality initiatives.
– Responsible for tracking feedback and clinical corrections from providers on condition specific reports and mailings.
– Provides clinical support for development, evaluation and revisions to the Plan’s Clinical Registry.
– Reviews, investigates and responds to clinical member grievances.
– Responsible for review, investigation, tracking, trending and annual reporting of medical adverse events/serious reportable events including follow up and corrective
actions in conjunction with the Plan medical directors. Recommends to the CMO cases for non-payment status.
– Collaborates with NH Quality staff to develop interventions for QAPI activities.
– Responsible for identification, approval, tracking, distribution and reporting of medical Clinical Practice Guidelines.
– Works with other areas (e.g. Care Management, Marketing and Communications, Clinical Informatics, Provider Relations) to develop and implement new clinical quality
programs including development of program descriptions, assessments, educational materials and interventions.
– Reviews and updates identified Clinical Policies and Procedures as assigned
– Provides support to the Accreditation Manager for achieving NCQA accreditation for the MA Medicaid and QHP products.
– Serves as an organizational resource for quality improvement methodology.
– Works to develop systems to collect, analyze, and report quality data.
– Other duties as assigned.

Qualifications:

Education:
– Bachelors’ Degree in nursing, health administration or related field required
– Registered Nurse with active license
– Master’s Degree in health related field preferred

Experience Required:
– Seven years of experience in progressively responsible healthcare quality improvement experience
– Experience working with Medicaid recipients and community services

Experience Preferred/Desirable:
– Experience working in a managed care organization
– Experience with NCQA accreditation standards

Required Licensure, Certification or Conditions of Employment:
– CPHQ certification strongly preferred

Competencies, Skills, and Attributes:
– Effective collaborative and proven process improvement skills
– Strong oral and written communication skills; ability to interact within all levels of the organization
– Proficient in use of Microsoft Office products
– Demonstrated ability to successfully plan, organize and manage projects
– Detail oriented, excellent proof reading and editing skills

Working Conditions and Physical Effort:
– Ability to work in a fast paced environment
– Work is normally performed in a typical interior/office work environment
– No or very limited physical effort required. No or very limited exposure to physical risk

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