Health Plan of San Joaquin/Mountain Valley Health Plan · 23 hours ago
HEDIS & NCQA Director
California, United States
Full-time
Hybrid
Mid, Senior Level
$170K/yr - $250K/yr
5+ years expHealth Plan of San Joaquin is looking for a talented HEDIS & NCQA Director to join our team! The role is responsible for providing strategic direction for HEDIS, Medicare Stars, and NCQA accreditation activities, ensuring compliance with regulatory requirements and overseeing quality management programs.
Health CareHealth InsuranceInsurance
Hiring Manager
Lori Loop
Responsibilities
Leads the development operational objectives and plans; ensures the development and implementation of associated Quality, Accreditation, HEDIS and Stars, CAHPS and HOS business plans and tactics meet CMS, DHCS, DMHC and NCQA requirements
Oversee the HEDIS and Stars process of monitoring, reporting and implementation of interventions for improvement
Anticipates the need for and develops and implements relevant and effective quality management programs based on opportunities, issues and trends
Assists Chief Medical Officer and Medical Director and Executive Director of Quality Improvement and Health Equity in identifying claims and coding issues related to HEDIS, Stars, CAHPS and HOS
Collaborates with medical management and other departments to ensure that the Quality program meets or exceeds CMS, DHCS, DMHC and NCQA and regulatory standards
Ensures the effective implementation of the Quality Improvement and Health Equity Transformation Program, Work Plan and Annual Evaluation
Collaborates with internal and external stakeholders to develop programs that increase awareness and provide educational opportunities to providers and members regarding Health Plan’s Quality Improvement program goals and activities, as well as compliance issues for HEDIS and NCQA
Conducts or oversees the preparation, implementation and corrective action plans for internal and external quality monitoring activities to ensure practice adhere to preventive and condition management guidelines, NCQA requirements, regulatory guidelines and Health Plan criteria by overseeing the CMS, DHCS, DMHC and NCQA regulations for quality metric reporting and accreditation activities
Acts as subject matter expert and key points of contact for vendor relationships related to NCQA, HEDIS, incentives and surveys
Develops or oversees the development of relevant, timely and accurate internal and external quality reports, advising leadership as appropriate
Develops, manages or advises on department budgets; implements appropriate interventions
Develops, implements and maintains appropriate and required records, documents, policies and procedures, including contracts. Collaborates with internal and external stakeholders to ensure the collection, storage and retrieval of relevant data and information
Leads or participates in internal and external committees as assigned
Promotes and maintains and ensures that direct reports promote and maintain an environment that supports Health Plan’s strategy, vision, mission and values
Hires, develops and retains, and ensures that subordinate managers hire, develop and retain, a competent staff
Qualification
Required
Strong clinical skills
Expert knowledge of NCQA standards and their application to quality and disease management, and ability to develop and implement effective programs and improvement activities
Expert knowledge of CMS and HEDIS measures, and ability to develop and implement effective programs and improvement activities
Expert knowledge of population health management best practices, and ability to develop and implement effective plans
In-depth knowledge of and proficient skills in administering protocols for quality improvement
In-depth knowledge of regulatory requirements pertaining to quality management
Strong knowledge of medical management information systems and their interrelationships
In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them
Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions
Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results
Ability to develop and manage realistic budgets
Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems
Decision quality: Makes good and timely decisions that keep the organization moving forward
Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies
Ability to translate strategic concepts into actionable business plans
Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities
Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals
Ensures accountability: Holds self and others accountable to meet commitments
Drives results: Consistently achieve results, even under tough circumstances
Very strong interpersonal skills with the ability to initiate establish and maintain effective working relationships with diverse individuals both inside and outside of Health Plan
Very strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of Health Plan; includes the ability to effectively explain complex information
Very strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups
Very strong collaboration skills with demonstrated ability to create and foster a collaborative work environment
Strong project management skills, including the ability to manage organizational-wide projects to successful conclusions
Build networks: Effectively build formal and informal relationship networks inside and outside of the organization
Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics
Persuades: Uses compelling arguments to gain the support and commitment of others
Manages ambiguity: Operates effectively, even when things are not certain or the way forward is not clear
Strong knowledge of change management theory, with ability to anticipate and implement effectively
Strong customer service skills
Demonstrated ability to articulate and support Health Plan's vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff
Ability to supervise staff, and ensure that direct reports supervise staff, in a manner that maximizes employee performance and business results, includes very strong coaching/counseling skills, including the ability to function as a mentor to management and employees
Intermediate mathematics skills, including basic algebra
Intermediate skills in Word, Excel and Outlook, including the ability to develop spreadsheets, formulas, and create tables and graphs
Ability to speak and be understood in English
Ability to handle confidential information with appropriate discretion
Bachelor's degree in nursing, business management or related fields
At least five years managing HEDIS and/or NCQA
At least five years supervisory experience in a healthcare setting
Preferred
Current unrestricted California RN license
Benefits
Competitive salary
Robust and affordable health/dental/vision with choices in providers
Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
Two flexible spending accounts (FSAs)
Employer-Paid Term Life and AD&D Insurance
Employer-Paid Disability Insurance
Employer-Paid Life Assistance Program
Health Advocacy
Supplemental medical, legal, identity theft protection
Access to exclusive discount mall
Education and training reimbursement in addition to employer-paid elective learning courses.
A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
Company
Health Plan of San Joaquin/Mountain Valley Health Plan
Health Plan of San Joaquin/Mountain Valley Health Plan (not-for-profit health plan) is the leading Medi-Cal managed care provider in San Joaquin in Stanislaus Counties, now serving Medi-Cal members in Alpine in El Dorado Counties.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Lizeth Granados
Chief Executive Officer
Michelle Tetreault
Chief Financial Officer | Interim Chief Executive Officer (2019)
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