Quality Incentive Performance Consultant at Blue Cross Blue Shield of Michigan in Detroit, Michigan

Job Description:

Provide support to the Leadership of Medical Care Groups (MCGs) and Physician Organizations (POs) that are in risk-based contracts for BCN HMO, Medicare Advantage PPO and Medicare Advantage HMO; focusing on HEDIS and CMS Star performance through quality incentive programs.

• Work collaboratively with MCGs/POs leadership and clinical quality staff to improve utilization and quality performance in HEDIS and CMS Stars ratings, which in the end, helps providers and physician organizations to receive additional rewards (reimbursement), while helping the enterprise maintain NCQA accreditation.


• Develop strategies to improve MCG/PO quality performance in HEDIS and Stars programs and identify opportunities for improvement or other root causes impacting performance.


• Responsible for future educational efforts on commercial risk contracts in the Blueprint for Affordability initiative.


• Conduct regular meetings with MCGs/POs and provide support to ensure that program requirements are understood, and organizations are aware of program changes or enhancements that may impact quality metrics.


• Proactively reach out to groups with frequent communication (4-12 meetings per year, per group) to discuss performance and develop strategies to capitalize on opportunities for improvement.


• Respond to and resolve MCG/PO questions and issues in a timely manner.


• Conduct provider information sessions/presentations at the request of assigned MCG/PO leadership to support program changes.


• Conduct data analysis and research and provide trending reports to MCG/PO leadership.

• Bachelor’s degree required.  Master’s degree in related field preferred.


• Registered nurse with unrestricted current Michigan license preferred, with 5 years of practical experience required.


• Four (4) years of administrative or clinical experience in health care related field required.


• Knowledge of managed care principles, case management, quality management, disease management programs, HEDIS and CMS Star programs.


• Excellent analytical skills and experience in assessing clinical utilization and quality reports.


• Knowledge of managed care financial risk models and reimbursement methodologies.


• Excellent verbal and written communication skills including the ability to conduct presentations with internal and external customers (including administrative and clinical leaders).


• Ability to identify individual needs and areas of opportunity for Medical Care Groups (MCG) or Physician Organizations (PO) and create appropriate support/action plans.


• Excellent statistical and analytical skills.


• Excellent organizational skills, including the ability to handle multiple projects and timelines.


• Ability to be self-directed and work independently.


• Commitment to continual learning and staying up to date with annual program changes and updates to HEDIS and CMS star programs.


• Proficient in Microsoft Word, Power Point, Excel and Access.

Department Summary / Preferences:

Ability to work independently, self-starter

Customer service/Interpersonal skills – internally and externally, able to work effectively in a team environment

Analytic skills

Ability to problem solve and identify opportunities for improvement/develop action plans

Oral and written communication skills – preparing materials and executing presentation (consider making mention of audience? Ie. Medical directors, executives, etc).

Ability to multi-task  - manage multiple projects and adapt to change according to priority/deadline

Efficient in Microsoft Office  -  Outlook, Excel, Powerpoint, Word

Able to travel

PREFERRED:

Knowledge of HEDIS, Patient Experience, and CMS Stars

Knowledge of contracting

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.