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Quality Improvement Operations
- Provide direction and manage HMSA's overarching Quality Improvement program, including the oversight of staff and necessary resources required to design and implement programs related to compliance with accreditation, regulatory and program requirements (e.g., NCQA, Med-QUEST, CMS, OPM, etc.). Oversee project teams and provide guidance to subject matter experts through planning, development, implementation, and evaluation to ensure programs meet standards, are measurable, and prepared for related audits.
- Manage committees, delegated entities, and subgroups to comply with accreditation standards and regulations.
- Select, develop, and manage staff. Provide coaching, feedback, and performance evaluations to ensure effective business practices and departmental goals are met.
- Monitor and take appropriate action to ensure various task and system-related deliverables are accomplished in an accurate and timely manner.
- Identify and actively resolve issues that hinder program efficiencies or outcomes.
- Manage and direct ongoing assessment of business functions for numerous departments within the scope of NCQA standards (e.g., Provider Services, Utilization Management, Medical Management, Integrated Health Management Services, Customer Relations, etc.) to support high-quality performance and ensure successful NCQA re-accreditation.
- Assess business area functions against current and upcoming NCQA standards and identify potential performance gaps and associated risks.
- Recommend and facilitate business area process improvements via means such as policies, workflows, and processes; follow-up to ensure improved outcomes.
- Collaborate with cross-departmental teams to identify and implement organization-wide strategic initiatives that support HMSA's quality performance.
- Every three years, serve as HMSA's internal lead for NCQA's re-accreditation review by gathering all necessary documents and information from business areas, managing timely document submissions to NCQA, facilitating NCQA requests for additional information, and coordinating onsite review activities.
- Create and foster working relationships with internal and external parties that facilitate accreditation/regulatory audit and QI program success. Responsible for serving as Program lead and/or co-lead of quality sub-committees.
- Effectively conduct meetings and discussions to achieve consensus and to identify actionable tasks.
- Achieve service commitments from core and support functional areas.
- Prioritize, track, and manage program deliverables.
- Ensure program documentation and reporting are complete and meet compliance requirements.
Delegation Oversight and Collaboration
- Oversee accredited delegation relationships and quality improvement activities with HMSA's strategic partners and with key departments, including, but not limited to Medical Management, Medical Directors, Provider Services, and the respective product line owners to attain and maintain compliance in accordance with HMSA policies and procedures, federal and state laws and regulations, and accreditation standards applicable to the quality of healthcare delivery and clinical standards across all product lines. Provide education and training to stakeholders on their respective roles in carrying out these programs.
- Develop and maintain delegation and contractual language that meets audit specifications and serves the best interest of HMSA's QI program. Participate in contracting activities, when appropriate.
Establish and ensure systematic oversight functions to manage change through change control and quality assurance workflows.
Oversee the development and implementation of work plans as appropriate and ensure follow-up to achieve compliance. In addition, ensure audit readiness for accreditation bodies such as NCQA, URAC etc.
Manage ongoing program dynamics ensuring the continued impact and performance of delegates.
Ensure changes to program components are analyzed, fully communicated to impacted parties, and implemented in a timely manner.
Complaints and Grievances
- Direct the provider service quality/quality of care complaint process related to the quality of delivery of healthcare services to ensure resolution and an integrated process with other HMSA departments and lines of business.
- Ensure ongoing reporting and analysis of trends related to complaints and appeals, making recommendations for improvement as appropriate
Model of Care Effectiveness
- Manage staff charged with the oversight and maintenance of the Medicare Advantage Dual Special Needs Population (DSNP) Model of Care (MOC) Effectiveness Measures. Provide guidance to staff and internal business areas when opportunities for improvement are identified. Participate and support activities related to changes or revisions to the MOC.
Administrative Functions/Miscellaneous
- Prepare annual unit plan and budget, monitor regularly, and take appropriate action to manage actual expenses again budgeted expenses.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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HMSA
April 08, 2024