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Quality Improvement Program Manager

2 months ago

Honolulu, Hawaii, United States Hawaii Medical Service Association Full time
Job Overview

**Hybrid Work Environment - Must reside on Oahu **

Compensation Range: $78,000 - $153,000, with eligibility for an incentive bonus

Note: New hires typically start between the lower to mid-range of the compensation scale.

The Quality Improvement Program Manager is tasked with overseeing personnel and ensuring the effective planning, execution, and management of accreditation initiatives and associated quality enhancement program responsibilities.

Essential Qualifications

  1. Bachelor's degree in a health-related field, Business Administration, or a similar discipline, coupled with six years of relevant professional experience; or a comparable mix of education and experience, including:
    • A minimum of five years in project management.
    • At least two years of previous supervisory or managerial experience.
  2. Comprehensive understanding of compliance and regulatory standards, including but not limited to:
    • National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), and Center for Medicare and Medicaid Services (CMS).
  3. Proven ability to interact effectively with individuals at all levels of management.
  4. Strong communication and interpersonal skills.
  5. Basic proficiency in Microsoft Office applications, including Word, PowerPoint, and Outlook.
  6. Intermediate proficiency in Microsoft Excel.
Key Responsibilities

Quality Improvement Operations
  1. Lead and manage the overarching Quality Improvement program, ensuring the provision of direction and resources necessary for the design and implementation of programs that comply with accreditation, regulatory, and program requirements (e.g., NCQA, Med-QUEST, CMS, OPM, etc.). Oversee project teams and guide subject matter experts through planning, development, implementation, and evaluation to ensure programs meet standards, are quantifiable, and are prepared for audits.
    • Manage committees, delegated entities, and subgroups to adhere to accreditation standards and regulations.
    • Select, develop, and oversee staff, providing coaching, feedback, and performance evaluations to ensure effective business practices and departmental objectives are achieved.
    • Monitor and take necessary actions to ensure timely and accurate completion of various tasks and system-related deliverables.
    • Identify and proactively resolve issues that impede program efficiency or outcomes.
  2. Direct ongoing assessments of business functions across multiple departments in line with NCQA standards (e.g., Provider Services, Utilization Management, Medical Management, Integrated Health Management Services, Customer Relations, etc.) to support high-quality performance and ensure successful NCQA re-accreditation.
    • Evaluate business area functions against current and upcoming NCQA standards, identifying potential performance gaps and associated risks.
    • Recommend and facilitate process improvements in business areas through policies, workflows, and procedures; follow up to ensure enhanced outcomes.
    • Collaborate with cross-departmental teams to identify and implement organization-wide strategic initiatives that bolster quality performance.
    • Serve as the internal lead for NCQA's re-accreditation review every three years, gathering necessary documents and information from business areas, managing timely submissions to NCQA, facilitating requests for additional information, and coordinating onsite review activities.
  3. Establish and nurture working relationships with internal and external stakeholders to facilitate the success of accreditation/regulatory audits and quality improvement programs. Responsible for leading or co-leading quality sub-committees.
    • Effectively conduct meetings and discussions to achieve consensus and identify actionable tasks.
    • Secure service commitments from core and support functional areas.
    • Prioritize, track, and manage program deliverables.
    • Ensure program documentation and reporting are thorough and comply with requirements.
Delegation Oversight and Collaboration
  1. Oversee accredited delegation relationships and quality improvement activities with strategic partners and key departments, including Medical Management, Medical Directors, Provider Services, and respective product line owners, to ensure compliance with HMSA policies, federal and state laws, and applicable accreditation standards for healthcare delivery and clinical standards across all product lines. Provide education and training to stakeholders regarding their roles in these programs.
    • Develop and maintain delegation and contractual language that meets audit specifications and serves the best interests of HMSA's quality improvement program. Participate in contracting activities as necessary.
    • Establish systematic oversight functions to manage changes through quality assurance workflows.
    • Oversee the development and implementation of work plans as appropriate, ensuring follow-up to achieve compliance and audit readiness for accreditation bodies such as NCQA, URAC, etc.
    • Manage ongoing program dynamics to ensure the sustained impact and performance of delegates.
    • Ensure that changes to program components are analyzed, communicated to affected parties, and implemented promptly.
Complaints and Grievances
  1. Direct the provider service quality/quality of care complaint process related to healthcare service delivery to ensure resolution and integration with other HMSA departments and lines of business.
  2. Ensure ongoing reporting and analysis of trends related to complaints and appeals, making recommendations for improvements as necessary.
Model of Care Effectiveness
  1. Manage staff responsible for overseeing and maintaining the Medicare Advantage Dual Special Needs Population (DSNP) Model of Care (MOC) Effectiveness Measures. Provide guidance to staff and internal business areas when opportunities for improvement are identified. Participate in and support activities related to changes or revisions to the MOC.
Administrative Functions/Miscellaneous
  1. Prepare the annual unit plan and budget, monitor regularly, and take appropriate actions to manage actual expenses against budgeted expenses.
  2. Perform all other miscellaneous responsibilities and duties as assigned or directed.