Director HEDIS & Provider Quality Incentives - Jefferson Health Plan

Job Details

The Healthcare Economics (HCE) team's primary function is to provide various clinical and financial analyses to management to support the business decision process. In addition, the team will provide consistent, accurate reports to help management from other departments do their jobs more effectively.
The director will oversee regulatory audit activities for HEDIS and lead the efforts surrounding data collection, software development, quality review of data and rate generation. The director will be directly responsible for ensuring compliance and timely submission of the annual HEDIS project for all lines of business as well as all relevant activities to ensure successful outcome. Additionally the director will oversee the planning, forecasting, reporting and payment (around $12M annually) for both the Provider Quality Incentive Plus (QCP) and Maternity Provider Quality Incentive Plus (MQCP) Programs. The director will also be responsible for supporting the needs of the Patient Centered Medical Home (PCMH) program.

Job Description

• Able to work in a constant state of alertness and safe manner
• Direct the entire HEDIS and Pennsylvania EQRO process.
• Oversee the planning, forecasting, reporting and payment for (QCP) and (MQCP) Programs.
• Support the needs of the PCMH program.
• Supervise and manage analyses for senior management and other departments to assure accuracy and integrity of work performed and relevance to the business needs identified.
• Motivate analysts to meet and exceed service requirements and functional objectives.
• Coach and lead HEDIS team to continuously improve performance and value.
• Serve as HPP’s liaison with third party vendors such as Inovalon to analyze HEDIS data in order to improve quality.
• Work with other department leaders to define and implement their reporting needs with regard to HEDIS and serve as a broker of available information.
• Assure that HEDIS staff meet the requirements of their reporting departments and that practices are in compliance with company standards.
• Coordinate, assign and respond to data requests from other departments. Maintain and foster a collaborative relationship with these departments.
• Participate in companywide initiatives such as new system implementations, quality and process improvement. Ensure that data and reporting needs are considered in plan-wide initiatives.
• Create accurate and meaningful utilization and outcome analysis, trend and other reports for departmental and management HEDIS related decision-making using Hyperion, MS Access, MS Excel and other reporting tools as necessary.
• Help determine optimal analysis and presentation of medical data to improve service quality. Direct use of dashboards, presentations, and spreadsheet reports accordingly.
• Work with IS to ensure that optimal business and reporting tools are available for HEDIS, STARS and other company users. Monitor data initiatives with IS, Operations and other departments to ensure accuracy and consistency and to avoid duplication of effort.
• Understand and communicate to HEDIS staff how changing business practices will affect data and reporting, and implement the necessary changes efficiently and accurately.
• Attend and participate in quarterly Quality Review Meetings (QQRM) for DHS and CHIP. Provide insight into quality trends and report to the state.
• Other responsibilities as assigned.

Minimum Qualifications

• Bachelor’s Degree in actuarial science, mathematics, statistics or other analytical field of study.
• 5 years of data reporting and analysis experience with at least 3 years of clinical/healthcare data experience in managed care and/or medical quality assurance setting or other relevant experience. and
• 2 years Experience with Medicaid and Medicare insurance and populations. Experience with provider coding practices using CPT, ICD-10 codes, and DRG’s. and
• 1 year Understanding of delivery and reimbursement of medical services in a managed care environment. Familiarity with the role disease management, utilization management and care management play in a managed care organization. and
• Less than 1 year HEDIS program management required.
• Proven leadership or mentoring skills with a data analysis team.
• Strong problem-solving, quantitative and analytical skills.
• Ability to use business intelligence query tools, computer spreadsheet (Excel), and databases at advanced level.
• Ability to manage technical staff.
• Proven skills with data presentation including charts, graphs and other exhibits.
• Ability to communicate effectively both orally and in writing.
• Ability to negotiate workable solutions to customer needs.
• Ability to learn quickly and implement knowled