Senior Director, Performance Improvement

UHS•Reno, NV

12h

About The Position

The Senior Director, Performance Improvement provides strategic leadership in the planning, development, implementation and execution of all aspects of a robust Risk Adjustment and STARS/HEDIS Program across Prominence Health Plan’s (PHP) Medicare Advantage and Commercial lines of products. The objective of this position is to ensure compliance with CMS coding and documentation requirements in order to optimize clinical quality and revenue opportunities for Prominence Health Plan as well as to oversee of the comprehensive quality measurement initiatives such as HEDIS and STARS, including reporting and compliance maintenance. Key responsibilities include optimizing PHP revenue opportunities by ensuring members receive appropriate medical care that is accurately coded so that the members’ risk scores are optimized and compliant with regulatory reporting standards. The Senior Director oversees all aspects of the plan’s HEDIS operations including measure improvement programs, data integrity, chart retrieval and abstraction efforts, audit compliance, and annual submission or rates as well as identifies strategies to improve performance across all STARS/HEDIS measures. The Senior Director has programmatic oversight and responsibility for achieving all risk adjustment, quality, and member satisfaction performance goals of the Prominence Care Centers. The Senior Director works closely with clinical and business leaders and oversees the development and implementation of population health and quality improvement initiatives aligned with PHP’s clinical, business, quality measurement, and improvement strategies. Must work collaboratively with other PHP departments, including Actuarial, IS, Legal, Health Services, Network Management, Quality Improvement and others to manage the risk adjustment and STARS process. Must develop or purchase tools that will result in leveraging information to manage member analytics in order to more effectively direct resources and activities to meet risk adjustment and STARS objectives. In carrying out these responsibilities, The Senior Director works closely with external vendors and consultants, runs outsourced health risk assessment programs, develops training programs & tools to address the educational needs of providers and non-clinical staff, assists in the development of analytic and reporting tools, and assists in the development of data collection systems and workflows to fulfill CMS and quality measurement requirements

Requirements

Master’s Degree in Business Administration, Finance, Health Care Administration, Management or related field preferred.
At least 5 years of health care experience working with Medicare Advantage STARS/HEDIS programs.
At least 3 years of health care experience working with Medicare and/or Commercial risk adjustment programs. Requires working knowledge of CMS risk adjustment methodologies and quality improvement measures.
Ability to effectively communicate in English, both verbally and in writing.
Knowledge of regulatory quality-based reporting and audit requirements;
Proficiency in interpreting results and formulating recommendations/action plans;
Ability to research and analyze state/federal regulations related to health insurance and healthcare;
Demonstrated skills in critical thinking, problem-solving, and the analysis, interpretation and evaluation of complex information;
Excellent computer skills. Microsoft Office Suite
Personable and demonstrated ability to develop and maintain relationships at all levels.
Well organized and demonstrate strong attention to the detail
Ability to understand, present and analyze data.
Strong verbal and written communication skills.
Versatile and flexible. Inquisitive mind with strong analytical skills and the ability to do complex problem solving.
Strong project management, meeting process and presentation skills.

Responsibilities

planning, development, implementation and execution of all aspects of a robust Risk Adjustment and STARS/HEDIS Program
ensure compliance with CMS coding and documentation requirements
optimize clinical quality and revenue opportunities
oversee comprehensive quality measurement initiatives such as HEDIS and STARS, including reporting and compliance maintenance
optimizing PHP revenue opportunities by ensuring members receive appropriate medical care that is accurately coded so that the members’ risk scores are optimized and compliant with regulatory reporting standards
oversees all aspects of the plan’s HEDIS operations including measure improvement programs, data integrity, chart retrieval and abstraction efforts, audit compliance, and annual submission or rates as well as identifies strategies to improve performance across all STARS/HEDIS measures
programmatic oversight and responsibility for achieving all risk adjustment, quality, and member satisfaction performance goals of the Prominence Care Centers
works closely with clinical and business leaders and oversees the development and implementation of population health and quality improvement initiatives aligned with PHP’s clinical, business, quality measurement, and improvement strategies
works collaboratively with other PHP departments, including Actuarial, IS, Legal, Health Services, Network Management, Quality Improvement and others to manage the risk adjustment and STARS process
develop or purchase tools that will result in leveraging information to manage member analytics in order to more effectively direct resources and activities to meet risk adjustment and STARS objectives
works closely with external vendors and consultants, runs outsourced health risk assessment programs, develops training programs & tools to address the educational needs of providers and non-clinical staff, assists in the development of analytic and reporting tools, and assists in the development of data collection systems and workflows to fulfill CMS and quality measurement requirements