Mgr, Quality Management

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

About the Role

This position is responsible for leading all aspects of Quality Management Clinical Operations & Audit and Quality Management Performance Reporting, including HEDIS and STARS performance for Horizon Government Programs.

What You'll Do

• Directs staff to support quality improvement initiatives specifically related to Quality Audit, HEDIS, Stars, and NQCA Accreditation

• Develops policies and procedures to support quality improvement initiatives and processes

• Participates in special projects as assigned by the Director.

• Represents the department with internal customers and Sr. Leadership in the event of Director's absence

• Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.

• Provide leadership and utilizes professional and communication skills to direct and motivate staff to ensure high quality outcomes.

• Represents the Plan with external customers, providers and external agencies and represents the unit on corporate issues and/or in the event of Director's absence

• Manage, direct, and develop staff by providing feedback and coaching. Administer performance, and salary review for staff. Ensure staff meets all regulatory requirements and utilizes best practice methodology.

QM Performance Reporting

• Develop annual HEDIS chart review training and administer inter rater reliability

• Develop HEDIS provider chase strategy to meet Horizons goals

• Oversees Quality Management compliance of HEDIS chart reviews and overreads.

• Responsible for development and implementation of HEDIS Roadmap.

• Develops and implements initiatives to improve HEDIS and Stars performance

• Management and oversight of Horizons Pay for Performance program

• Conduct provider onsite visits to promote and support Pay for Performance program

• Manage relationships and supports external providers to improve HEDIS and Stars performance

• Collaborate with Value Based Programs and Provider Contracting and Services to manage provider quality performance.

QM Clinical Operations

• Develops and implements strategies for quality improvement and initiatives.

• Responsible for assuring timely correction of deficiencies, identification of problem providers and promptly reports difficulties or lack of cooperation to the Director of Quality Management.

• Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.

• Works with Utilization Management to develop related policies and procedures.

What You Bring

Education/Experience:

• Requires a Bachelor's degree from an accredited college or university

• Requires five (5) year experience in a healthcare setting: health plan, hospital, physician practice, or managed care organization

• Requires a minimum of five (5) years quality management experience

• Requires minimum of five (5) years management experience

• Requires project management experience.

• Masters Degree preferred

• Prefers experience in continuous quality improvement and/or quality management

Knowledge:

• Requires knowledge of HEDIS, CAHPS, and Medicare Stars

• Requires working knowledge of NCQA accreditation standards.

• Requires thorough knowledge of managed care products

• Requires knowledge of MCO and Horizon BCBSNJ products, services and programs.

• Requires the ability to think analytically and to use logic in the solving problems

• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, Power