Director, HEDIS & NCQA

SAN JOAQUIN COUNTY HEALTH COMMISSION•French Camp, CA

1d•Remote

About The Position

The Health Plan of San Joaquin is now hiring an experienced and dedicated Director, HEDIS & NCQA! Location: We are looking for someone who lives in our service area. (Must reside in California.) Remote: This is a remote position; however, must be able to attend onsite meetings, and as needed for business and community purposes. What You Will Be Doing: Under general supervision responsible for providing strategic direction of Healthcare Effectiveness Data and Information Set (HEDIS), Medicare Stars, Consumer Assessment of Health Plan Providers and Systems (CAHPS) surveys, Health Outcomes Survey (HOS) and other related surveys as identified through regulatory or accrediting bodies. Provides strategic direction of the National Committee for Quality Assurance (NCQA) Health Plan and Health Equity Accreditations consistent with contractual and regulatory requirements, and Health Plan strategies and objectives. Work is varied and complex and requires a moderate to high degree of discretion and independent judgment.

Requirements

Strong clinical skills.
Expert knowledge of NCQA standards and their application to quality and disease management, and ability to develop and implement effective programs and improvement activities.
Expert knowledge of CMS and HEDIS measures, and ability to develop and implement effective programs and improvement activities.
Expert knowledge of population health management best practices, and ability to develop and implement effective plans.
In-depth knowledge of and proficient skills in administering protocols for quality improvement.
In-depth knowledge of regulatory requirements pertaining to quality management.
Strong knowledge of medical management information systems and their interrelationships.
In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.
Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results.
Ability to develop and manage realistic budgets.
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.
Ability to translate strategic concepts into actionable business plans.
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 achieve results, even under tough circumstances.
Very strong interpersonal skills with the ability to initiate establish and maintain effective working relationships with diverse individuals both inside and outside of Health Plan.
Very strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of Health Plan; includes the ability to effectively explain complex information.
Very strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
Very strong collaboration skills with demonstrated ability to create and foster a collaborative work environment.
Strong project management skills, including the ability to manage organizational-wide projects to successful conclusions.
Build networks: Effectively build formal and informal relationship networks inside and outside of the organization.
Organizational savvy: Maneuvers comfortably through complex policy, process and people- related organizational dynamics.
Persuades: Uses compelling arguments to gain the support and commitment of others.
Manages ambiguity: Operates effectively, even when things are not certain or the way forward is not clear.
Strong knowledge of change management theory, with ability to anticipate and implement effectively.
Strong customer service skills.
Demonstrated ability to articulate and support Health Plan’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
Ability to supervise staff, and ensure that direct reports supervise staff, in a manner that maximizes employee performance and business results, includes very strong coaching/counseling skills, including the ability to function as a mentor to management and employees.
Intermediate mathematics skills, including basic algebra.
Intermediate skills in Word, Excel and Outlook, including the ability to develop spreadsheets, formulas, and create tables and graphs.
Ability to speak and be understood in English.
Ability to handle confidential information with appropriate discretion.
Bachelor’s Degree in nursing, business management or related fields; and
At least five years managing HEDIS and/or NCQA; and
At least five years supervisory experience in a healthcare setting; or
Equivalent combination of education and experience.
Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by Health Plan if prohibited from getting a driver license due to a medically documented disability.

Nice To Haves

Knowledge of the principles and practices of managed care.
Knowledge of managed healthcare as applied to government sponsored programs including Medicaid and Medicare.
Knowledge of DHCS and Medi-Cal
Knowledge of managed care systems in a Knox-Keene licensed HMO.
In-depth knowledge of Medicaid especially as it relates to HEDIS and NCQA.
Master’s Degree in Nursing or other health care fields.
Experience in an HMO or managed care setting.
Experience in Quality for government sponsored programs.
Current unrestricted California RN license or license relevant to the field of specialization

Responsibilities

Leads the development operational objectives and plans; ensures the development and implementation of associated Quality, Accreditation, HEDIS and Stars, CAHPS and HOS business plans and tactics meet CMS, DHCS, DMHC and NCQA requirements. Leads and oversees NCQA accreditation activities to ensure ongoing compliance.
Oversee the HEDIS and Stars process of monitoring, reporting and implementation of interventions for improvement.
Anticipates the need for and develops and implements relevant and effective quality management programs based on opportunities, issues and trends.
Assists Chief Medical Officer and Medical Director and Executive Director of Quality Improvement and Health Equity in identifying claims and coding issues related to HEDIS, Stars, CAHPS and HOS.
Collaborates with medical management and other departments to ensure that the Quality program meets or exceeds CMS, DHCS, DMHC and NCQA and regulatory standards.
Ensures the effective implementation of the Quality Improvement and Health Equity Transformation Program, Work Plan and Annual Evaluation
Collaborates with internal and external stakeholders to develop programs that increase awareness and provide educational opportunities to providers and members regarding Health Plan’s Quality Improvement program goals and activities, as well as compliance issues for HEDIS and NCQA.
Conducts or oversees the preparation, implementation and corrective action plans for internal and external quality monitoring activities to ensure practice adhere to preventive and condition management guidelines, NCQA requirements, regulatory guidelines and Health Plan criteria by overseeing the CMS, DHCS, DMHC and NCQA regulations for quality metric reporting and accreditation activities.
Acts as subject matter expert and key points of contact for vendor relationships related to NCQA, HEDIS, incentives and surveys.
Develops or oversees the development of relevant, timely and accurate internal and external quality reports, advising leadership as appropriate.
Develops, manages or advises on department budgets; implements appropriate interventions.
Develops, implements and maintains appropriate and required records, documents, policies and procedures, including contracts. Collaborates with internal and external stakeholders to ensure the collection, storage and retrieval of relevant data and information.
Leads or participates in internal and external committees as assigned.
Promotes and maintains and ensures that direct reports promote and maintain an environment that supports Health Plan’s strategy, vision, mission and values.
Hires, develops and retains, and ensures that subordinate managers hire, develop and retain, a competent staff.

Benefits

Competitive salary
Robust and affordable health/dental/vision with choices in providers
Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
Two flexible spending accounts (FSAs)
Employer-Paid Term Life and AD&D Insurance
Employer-Paid Disability Insurance
Employer-Paid Life Assistance Program
Health Advocacy
Supplemental medical, legal, identity theft protection
Access to exclusive discount mall
Education and training reimbursement in addition to employer-paid elective learning courses.
A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.