Clinical Quality Stars Program Manager

4 days ago

Wheeling, United States The Health Plan of West Virginia Inc Full time
Job DescriptionJob Description

Under the leadership of the Vice President Quality Improvement, the Clinical Quality Stars Program Manager will coordinate the clinical operations for Medicare Star initiatives and other quality improvement initiatives that interface with Clinical Services, Pharmacy, Quality Improvement and the Medical Economics Departments. This position is responsible for maintaining a collaborative working relationship to develop quality improvement strategies through cross functional teams in conjunction with the Medicare Stars Manager.

Required:

  1. Registered Nurse with an active OH and WV nursing license or the ability to obtain multi-state licensure in OH or WV within 90 days of employment. Additional licenses may be needed per line of business.
  2. Minimum of ten years clinical experience with at least five of those years as a Registered Nurse.
  3. Minimum of two years of experience related to Medicare Stars, HEDIS, CAHPS, HOS.
  4. Minimum of three years of experience in quality improvement PDSA cycle.
  5. Minimum of three years in project management experience with demonstrated successful results.
  6. Strong leadership and organization skills with the ability to prioritize and pivot to achieve goals with minimal direction and supervision.
  7. Ability to build working relationships with internal staff and external stakeholders including community and vendor partners.

Desired:

  1. CPHQ certification or other quality improvement driven distinctions.
  2. Medicare Star Ratings experience with the ability to analyze and interpret cut point predictions.

Responsibilities:

  1. Communicates with the Medical Economics Department and Quality Improvement Departments to obtain ongoing HEDIS and Stars data collections to support and develop SMART goals.
  2. Works with internal departments to identify opportunities for improvement, gap closure and facilitates the development of member and provider clinical data driven initiatives to promote optimal member outcomes.
  3. Creates tracking systems for reporting KPIs for the evaluation of activities and the effectiveness related to Medicare Star program initiatives and other performance/quality improvement projects.
  4. Using the PDSA cycle, identifies barriers and opportunities for improvement related to Star ratings, NCQA, CAHPS and HOS surveys and other member experience or quality metrics.
  5. Collaborates with the Provider Delivery System Department and network provider clinical office staff to execute proper submission of medical records and data needed based on HEDIS specifications.
  6. Assists to development training and educational material that directly impacts quality initiatives.
  7. Participates in quality improvement meetings and committees/subcommittees and focus groups.

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