Sr. Program Manager, Clinical Quality

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The Role

The Sr. Program Mgr, Clinical Quality is responsible for developing, managing, coordinating, and contributing to numerous Health and Medical Management (HMM) cross-functional projects by establishing and maintaining a system that evaluates the quality of member care. These projects include supporting Case Management program design and quality improvement initiatives as a consult for NCQA accreditation standards (including monitoring for identification of risks and improvement opportunities). The role serves as a resource regarding accreditation standards including NCQA standards and continuous quality improvement principles.

This role also drives implementation of divisional accreditation requirements, prepares documentation for accreditation submission, provides delegation oversight, and evaluates other opportunities for improvement with clinical program and accreditation compliance. This includes working through influence, as an individual contributor and collaborating with other departments, external delegates, and team members to lead/support corporate initiatives. The role may also coordinate accreditation activities on behalf of the organization

The Sr. Program Manager, Clinical Quality works closely and collaboratively with all HMM areas, Performance Measurement and Improvement, and other key departments throughout BCBSMA to support quality improvement activities. The Program Manager reports progress and impediments toward progress on key improvement initiatives to the Clinical Quality Improvement Committee.

The Team

Under the direction of the Director of Clinical Quality, the Sr. Program Manager, Clinical Quality works collaboratively with the Clinical Quality team members on work related to quality performance initiatives.

Key Responsibilities:

• Supports organizational commitment to quality, engages stakeholders, provides consultation support to QI structure and committees, evaluates and integrates quality innovations, promotes population health management, utilizes evidence-based best practices when developing programs and measures, and leads and facilitates change.
• Collaborates and leverages relationships within HMM and with outside business partners, including but not limited to Performance Measurement and Improvement, Network Management and Contracting—all to advance quality improvement goals and accreditation activities relevant to population health and care management.
• Use CQI tools to facilitate improvement using evidence-based principles.
• Collects, analyzes, and validates data used in quality initiatives and presents findings within BCBSMA and to external audiences, including but not limited to providers and delegated entities.
• Evaluates existing and new NCQA standards for compliance.
• Manages collaboration with Operational Business Partners to drive improvement, including development of policies and workflows, monitoring ongoing compliance and identifying opportunities for improvement, documentation, and communication of risk analysis to all levels of the organization.
• Provides oversight of relevant delegates.
• Shares expertise with all HMM associates through educational opportunities and job shadowing, to improve quality improvement culture and skills within HMM.

Key Qualifications:

• Strong understanding of clinical quality improvement principles and techniques with the ability to creatively link these principles to the development and implementation of collaborative quality initiatives
• Demonstrated ability to review and communicate data and reports, and support analysis of the results and identify opportunities and interventions for improvement with the business.
• Able to manage all aspects of multiple projects simultaneously from conceptualization through development, implementation, and evaluation.
• Demonstrated project leadership skills and experience, including consensus building, negotiation, meeting facilitation, and the ability to manage change
• Exceptional organization and time management skills including the ability to meet deadlines, problem-solve, and manage multiple competing priorities within a matrixed environment.
• Knowledge of care management processes and MHK/care management information systems a plus

Education and Experience

• Typically requires a bachelor’s degree level RN/clinician with five or more years of clinical and managed care experience with two to three years of supervisory experience and

• 6-10 years of experience working on quality improvement/compliance management in relation to relevant NCQA Standards, CMS compliance or other oversight requirements or demon