Quality Improvement Facilitator III - Medicare Stars

Inland Empire Health Plan•Rancho Cucamonga, CA

6d•$104,042 - $137,842•Hybrid

About The Position

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Director, Medicare Stars, the Quality Improvement (QI) Facilitator III – Medicare Stars serves as a Medicare Stars regulatory and operational subject matter expert, ensuring Medicare-related quality improvement functions align with CMS regulations, CMS Star Ratings Program requirements, the Medicare Managed Care Manual, audit protocols, evolving CMS guidance, and IEHP organizational policies. This role independently leads and oversees complex Medicare Stars quality initiatives involving the prioritization of resource utilization, delegation of project deliverables, and application of quality concepts and standards to ensure improvements in organizational performance. This position translates CMS expectations into actionable workflows across operational, clinical, and provider facing teams. The QI Facilitator III facilitates Stars driven organizational improvement by applying improvement methodologies, managing cross functional project deliverables, and aligning initiatives with IEHP’s strategic goals for sustained Stars performance excellence. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

A minimum of six (6) years demonstrated experience, at a professional level, in process/project management including participation in quality improvement projects or operations
Prior experience in the health care setting required
Master’s degree in public health, health administration, public administration, or other healthcare related focus from an accredited institution from an accredited institution required
Project Management Professional (PMP) Certificate, Certified Professional of Healthcare Quality (CPHQ), or other recognized quality improvement certificate required or successful completion within one (1) year of hire
Must have a valid California Driver’s license
Advanced knowledge and in-depth understanding of: Healthcare quality performance and measurement sets including CMS quality withhold, NCQA Quality Improvement Standards and HEDIS
Project management techniques, tools of continuous improvement, and work process redesign
Standardized QI concepts
Standard coding sets as they are used in quality measurement including ICD-10, CPT, CPT Category II, HCPCS, LOINC, NDC
Advanced proficiency in: Analytical and critical thinking skills
All Microsoft Office applications, with an emphasis on Excel, PowerPoint, and Visio
Communication skills (verbal, written and listening) with ability to interact effectively and demonstrated comfort with public speaking to varied audiences
Successfully applying facilitation techniques to quality improvement project teams to achieve optimal outcomes
Problem solving, leadership qualities, conflict management, and team building skills to ensure a productive work environment and achievement of quality goals
Successfully working with and motivating diverse teams including group process facilitation, change management and conflict resolution
Teaching quality improvement concepts and principles
Demonstrated ability to: Increase Quality Ratings through targeted quality improvement activities
Read and interpret data
Be results and outcome oriented
Perform complex tasks, prioritize multiple projects and work under pressure to meet deadlines in a fast-paced environment
Successfully apply facilitation techniques to quality improvement project teams to achieve optimal potential
Demonstrate excellent project and time man agement skills
Exhibit high attention to detai

Nice To Haves

Prior experience designing Medicare Star Measure interventions preferred.
Demonstrated experience increasing Plan Star Ratings through targeted quality improvement activities preferred
Knowledge of Risk Adjustment calculations and financial analysis related to Medicare Advantage membership populations preferred
Strongly preferred advanced knowledge and understanding of: Risk Adjustment calculations and financial analysis related to Medicare Advantage membership populations preferred
CMS quality programs, Medicare Star Ratings methodology, HEDIS, CAHPS, Pharmacy Part D measures, NCQA standards, Risk Adjustment basics, and regulatory documentation requirements
Supporting CMS audits, data validation reviews, or compliance reporting
Medicare Managed Care Manual, HPMS guidance, and CMS regulatory updates.

Responsibilities

Serve as a Medicare Stars program expert consulting and coaching team members throughout the organization in the development of quality improvement initiatives surrounding CMS regulations, CMS Star Ratings Program requirements, the Medicare Managed Care Manual, and audit protocols.
Provide support to leadership with promoting IEHP strategic goals to achieve improvements in organizational performance
Participate in the onboarding of new quality improvement team members.
Coach and mentor Quality division staff on quality improvement concepts, lean principles, and implementation of process improvement experiments.
Provide quality improvement tools and training solutions for IEHP team members to address quality improvement gaps in knowledge, competency, or skills
Lead the facilitation of quality improvement projects and events of a complex nature with minimal oversight, including planning, implementation, assessment and follow up
Oversee multiple Quality Improvement initiatives and consistently meeting quality standards and deliverable timeframes
Translate data into meaningful information, draw conclusions, and relate findings to industry standards.
Provide recommendations to departmental stakeholders and QI Leadership Team regarding performance gaps, program implementation, and performance outcomes in order to maintain an effective QI Program
Guide the prioritization of resources which support quality initiatives and delegates assignment appropriately
Act as primary liaison between IEHP and regulatory agencies (e.g., CMS and/or other relevant agencies) for quality improvement submissions and communications
Monitor external quality improvement trends within the healthcare industry and how they impact the organization. Identify opportunities for improvement and communicates findings to leadership.
Partner with Compliance to ensure continuous monitoring of CMS rule changes and Medicare oversight requirements
Perform any other duties as required to ensure Health Plan operations and department business needs are successful