Manager Quality & Provider Education at Blue Cross Blue Shield of Michigan in Detroit, Michigan

Job Description:

Responsible for managing the annual HEDIS/STAR activities including annual EMR Audit, HEDIS fall medical record reviews and supplemental data collection for prospective HEDIS.

• Responsible for updating HEDIS specifications/information for managed care publications for practitioners, providers and members in newsletters, manuals, handbooks and website.


• Evaluates monthly HEDIS rates, to identify problems, provide analysis of barriers and develop recommendations for interventions and incentives, to positively impact HEDIS/STAR ratings.


• Participate on multidisciplinary committees and work teams. Identify opportunities for HEDIS rates improvement.


• Serves as liaison for other departments in achieving compliance with HEDIS measures, supporting corporate accreditation and regulatory initiatives, e.g. NCQA, CMS, etc.


• Actively and effectively communicates with Quality and Population Health (QPH) leadership including other QPH Managers, QPH Director, and VP of Health and Care Affairs regarding issues in the State that might impact HEDIS measures.


• Assists with requests for information/answering Health eBlue Web questions and special reports for department.


• Responsible for writing HCV business cases to support staff requirements for QPH area.


• Keep abreast of changes in corporate policies/procedures and communicates changes with staff.


• Assist the QPH Director with activities related to HEDIS, including expectations of HEDIS goals for rates, HEDIS interventions/incentives, and the implementation of departmental budget.


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• Bachelor’s Degree in Nursing, Business Administration, Health Care Administration or related field required. Master’s Degree preferred.


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  Three years of clinical practice as an RN required.
  


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  Three years of experience in medical record review and data abstraction for HEDIS activities required.
  


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  Two years supervisory or management experience required.
  


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  Current, active and unrestricted Michigan Registered Nurse license required.
  


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  Strong organizational, planning, analytical, strategic and communication skills.
  


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  Excellent leadership, analytical, organizational, verbal and written communication skills.
  


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  Ability to work effectively in a team environment.
  


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  Ability to develop and lead teams, directly and indirectly.
  


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  Strong interpersonal skills to maintain professional relationships with practitioners, providers, members and other external customers.
  


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  Maintain confidentiality in all aspects of departmental operations involving physicians, providers, members and external entities.