Program Manager - Full Time - 8:00am-5:00pm - Quality (HEDIS ) at Southwestern Health Resources CIN in Pittston, Pennsylvania

Job Description:

Southwestern Health Resources (SWHR CIN) seeks to hire a Program Manager Quality to join the Quality department.

Please note: Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.

The address is 8150 Brookriver Drive, Dallas, TX 75247 in the SWHR Corporate Office.

Salary range is Min $35.13 - Max $54.63 - based on relevant experience.

Full Time: 40 hours per week, Monday-Friday 8:00am-5:00pm.

The essential duties of this position are:

Vendor Management :
• Selection of vendor, completion of contracting and monitors and manages the performance of all vendor systems.
• Collaboration with Analytics for vendor monthly file extract (Monthly Rate Analysis and Data Integrity Checks), development/updates and Management of plan Supplemental Data Entry System to meet appropriate HEDIS specifications.
• Facilitation of collection/Aggregation of supplemental data from across the plan, submission of supplemental data to HEDIS Vendor for inclusion in HEDIS vendor monthly file extract.
• Subject matter expert HEDIS Quality measures and Medicare Star Program.
• Liaise with, and serve as key contact to external HEDIS vendors and auditors.

HEDIS Chase and Administration :
• Management of HEDIS Chart Chase Season (Vendor management, data validation coordination, pulling of sample, chase logic and strategies, medical record reconciliation).
• Annual HEDIS Audit Management (NCQA HEDIS Roadmap Completion, Primary Source Verification or PSV, Issue Log Management, Medical Record Question Log, Onsite Audit management, data accuracy and reporting, interacting with HEDIS auditors for regulatory compliance according to regulations).
• Develop and maintains a detailed HEDIS project plan to include milestones, tasks, and target/actual dates of completion.
• Manage the HEDIS auditing process including the preparation of the HEDIS Roadmap and all other documents required by auditors.
• Works with internal departments regarding data collection and submission.
• Responsible for providing leadership and direction to ensure the annual HEDIS submissions are delivered according to technical specifications and deadlines.
• Creates and makes formal presentations of trending reports throughout HEDIS cycle to keep executive management apprised of current status.
• Participate in the HEDIS review analysis to increase rates and evaluate and analyze annual HEDIS rates.
• Coordinates record retrieval with third party vendors and internal staff.
• Collaborates with internal departments for Supplemental Data process for HEDIS measures.

Program Management :
• Provide comprehensive analysis of HEDIS measures, barriers, and opportunities and present results of improvement efforts and ongoing performance measures to senior management.
• Collaboration with analytics for development /Maintenance of Quality Reports.
• Ensures accurate and timely reports shared with appropriates departments.
• Collaborates with quality and performance improvement to ensure plan meets contractual targets, Employs creative strategies to create develop new initiatives to increase plan overall star rating to 5 and maintain said rating year over year.
• Development of CMS 5 Star Calculators.
• Understand and SME to applicable regulatory and reporting requirements.
• Ensure program data accuracy and regulatory compliance for all materials or documents.
• Maintain knowledge of applicable rules, regulations, policies, laws, and guidelines that impact current CMS 5 Star technical specifications and HEDIS policies and procedures.
• Adjusts processes as needed to adhere to current regulations.
• Proactively identifies and communicates issues at risk.

• Makes suggestions to assigned manager and implements mitigation and contingency strategies as required.
• Other duties as assigned.

The ideal candidate will possess the following qualifications:

• Bachelor's Degree in Business Administration, Business Management, Computer Science, or relevant field Required
• Master's Degree Preferred

• 4 years' experience with a Health Plan / Medicare Advantage (MA) Organization working with HEDIS Project Management, Chart Abstraction, Vendor Relationships Required

• 3 years Project Management experience Required, preferably related to HEDIS, Quality Improvement, or other Accreditation Surveys

• Expert level knowledge of NCQA, HEDIS, Medicaid and Medicare Required
• Strong knowledge of STAR Ratings Preferred

Skills
• Work requires ability to effectively manage payor relationships related to Quality work
• Work requires excellent oral and written communication skills
• Work requires excellent organizational skills.
• Work requires strong analytical/problem solving skills.
• Work requires ability to prioritize and organize work to meet deadlines, as well as time management.
• Work requires demonstrated ability and skills with project management and quality improvement tools, such as Microsoft Project, Visio, Excel, and SharePoint.
• Ability to manage multiple, complex projects with strict HEDIS deadlines.
• Thorough understanding of Statistics, Data Analytics, Modeling, Reporting Methods and Data Mining Methodologies

• Resourcefulness as demonstrated by the effective application of professional knowledge to new situations. Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.