Manager, Clinical Quality Improvement

What You Will Do

• Leads the clinical audit team, ensuring compliance with Medicare STARS, HEDIS/QARR, and regulatory requirements.
• Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology.
• Oversees the quality review process, including the monitoring of provider and IPA performance to drive improvements in clinical quality and outcomes.
• Conducts provider education and training sessions on coding accuracy, documentation, and quality reporting to improve STARS and HEDIS scores.
• Acts as the primary clinical liaison for IPAs and provider networks, ensuring alignment with STARS, HEDIS, and clinical quality objectives.
• Works closely with IPAs and provider networks to optimize care coordination and member experience, addressing gaps in quality performance.
• Implements and refines audit methodologies to assess compliance with clinical quality standards and regulatory expectations.
• Collaborates with Quality leadership in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies.
• Investigates patient related complaints and quality of care (QOC) issues, incidents, and serious adverse reportable events in collaboration with internal staff and providers. Performs focused and comprehensive quality assessment reviews; identifies and analyzes results; prepares investigation summary reports; and creates/implements corrective action plan as appropriate. Analyzes data sets for trends and formulates opportunities for improvement based on those trends. Provides education about identified quality trends, outcomes of reviews and new requirements.
• Follows-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.
• Analyzes and reports quality data trends to leadership, identifying key opportunities for intervention and process improvements. Coaches, facilitates and monitors continuous improvement to attain strategic quality objectives and industry benchmarks for patient/member outcomes, satisfaction, cost and regulatory requirements.
• Supports CMS compliance and audit readiness, ensuring accurate and timely data submissions. Participates in the coordination, review, revision and approval of policies an d procedures for Provider Services. Identifies gaps and recommends creation of new policies.
• Develops and oversees corrective action plans for identified deficiencies, tracking progress and impact on STARS performance.
• Prepares for CMS and regulatory site visits, ensuring compliance with Medicare Advantage quality reporting standards. Participates in the preparation for and assists with site visits of outside surveyors/regulators for the purpose of regulatory compliance and accreditation.
• Partners with the education team to implement training programs for providers and care teams on STARS, HEDIS documentation, and best practices. Collaborates with Education department in the development of and implementation of quality related training programs and/or corrective action training related to identified deficiencies.
• Leads and/or participates on quality improvement committees and projects related to performance improvement, measurement and documentation.
• Keeps informed of the latest internal and external issues and trends in quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies and procedures to address these trends.
• Assists with analysis of member satisfaction surveys and audits including but not limited to the CMS Health Outcomes Survey, Consumer Assessment of Health Care Providers and Systems (CAHPS) or internal satisfaction surveys. Collaborates with Health plan staff to develop initiatives and action plans to improve member satisfaction.
• Participates in the development and implementation of quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, SNP Structure and Process, Quality Scorecard, IPRO Projects, and CMS Quality Projects.
• Performs all duties inherent in a managerial role, including hiring, training, developing, recommending salary actions and when necessary, terminating staff.
• Participates in special projects and performs other duties as assigned.