Quality Mgmt Specialist

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

About The Position

This position is responsible for supporting the Quality Management department with improvements through project planning, development and implementation, and the establishment of policies and procedures pertaining to regulations in both Government Programs and Commercial business.

Requirements

High School Diploma/GED required.
Requires five (5) years professional business experience working in a health care environment.
Requires knowledge of project management methodology.
Requires knowledge of healthcare management.
Requires working knowledge of PC and application software.
Requires knowledge of performance measurement and regulatory reporting.
Requires the ability to apply project management methodologies and practices across multiple projects.
Requires comprehensive leadership and decision making ability.
Requires excellent analytical and problem solving skills.
Requires excellent verbal and written communications skills.
Require excellent presentation skills.

Nice To Haves

Bachelor degree preferred or relevant experience in lieu of degree.
Prefer five (5) years managed care experience.
SAS Coding experience strongly preferred.
HEDIS/Quality Initiative experience strongly preferred.
State Reporting experience strongly preferred.

Responsibilities

Develop project initiatives, process and performance measures for Quality Management and deliverables to ensure positive outcomes defined by corporate objectives and NCQA and regulatory regulations.
Analyzes complex data and information to provide meaningful results, identifying success factors and improvement opportunities, recommending potential solutions to assist the business set strategic goals.
Responsible for budgeting, cost containment and strategic planning of systemic enhancements to improve the quality and efficiency of project initiatives and yearly interventions.
Collaboratively serve as a HCM&T divisional resource with the Manager for health plan quality ratings.
Interacts with internal and external stakeholders to promote HCM&T clinical and operational improvement activities.
Measure performance goals of Medicare STAR Program plans and initiatives to ensure effectiveness of process.
Report findings to management and stakeholders as appropriate.
Reviews all HPMS and industry correspondence, related to Star Ratings in order to assist and remain current on all information and decision.
Ensures that all information necessary for decision making is coordinated and any necessary documentation is prepared.
Provide Consumer Assessment of Healthcare Providers and Systems (CAHPS) coaching to the Horizon providers community to improve the member experience.
Interprets member experience performance through various sources of data.
Assist in the development of provider improvement action plans to improve member experience and improve CAHPS performance.