Manager Quality - Value Based Care (Hybrid Detroit/Jackson) - Mosaic CIN

GENERAL SUMMARY:
The Quality Manager is accountable for the standards outlined by National Committee for Quality Assurance (NCQA), Michigan Department of Health and Human Services (MDHHS), Centers for Medicare and Medicaid Services (CMS) and other certifying, regulatory and professional accreditation organizations.

This position is responsible for the overall implementation of the quality programs and interventions related to Medicaid and Medicare and manages the processes for NCQA accreditation, Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, Health Outcomes Survey (HOS), CMS quality reporting and compliance review requirements for the State of Michigan.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Responsible for the development, implementation, and management of Quality Management (QM) programs and initiatives within the health plan; establishes QM objectives, policies and procedures, and annual goals based on prior year performance evaluation.
• Ensure efforts to fulfill regulatory standards including NCQA and compliance for the MDHHS and CMS reporting; ensures timelines of standards for submission are met.
• Provides training and education to key plan leaders and staff to meet NCQA standards and MDHHS compliance; assure readiness and appropriate communication related to surveys and site visits.
• Manages the activities of the department to support the quality management program and interventions.
• Establishes strategic plans; oversees policies and procedures and clinical practice guidelines at all levels and with all critical operation departments to ensure quality programs are consistent with overall quality strategies.
• Coordinate and conduct annual reviews of high volume PCP's in the areas of Appointment Wait Times and After Hours Access to Care.
• Responsible for all federal and state reporting requirements for the Medicare programs. Ensures timely and accurate reporting into HPMS for quarterly, semi-annual and annual reporting to CMS for part C and Part D reporting requirements.
• Coordinates development, implementation, and evaluation of continuous quality management action plans for the activities specific to CAHPS, HOS, state based performance programs, CMS reporting requirements, External Quality Review Organizations (EQRO) or other audit or annual evaluation findings.
• Monitor member complaints to identify potential quality of care and/or provider site issues that require a credentialing site visits or follow-up action plan.
• Works in conjunction with leadership team to ensure strategies for attaining a 3.5 star rating or better are successfully implemented for the Medicare products.
• Works with HAP departments to ensure all CAHPS and HOS activities are accomplished timely and accurately.
• Organize the plan quality management committee (QMC); responsible for meeting preparation, notice, agenda, materials and minutes.
• Partake in professional work groups, as assigned, including but not limited to the Michigan Association of Health Plans (MAHP), the Michigan Quality Improvement Consortium (MQIC), MDHHS initiatives, health plan initiatives, State and local committees, etc.
• Other quality management activities, as directed by the Director of Outreach, DM, Quality.
• This position will be focused on Centers for Medicare & Medicaid programs to support ACOs.