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Tenet Healthcare Director Quality Improvement (Encino, CA) in Frisco, Texas

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The Director, Quality Improvement is responsible for the implementation and coordination of Health plan Pay of Performance (P4P) Medi-Cal Incentive Program, HCC risk adjustment, Star Program and other Incentive programs for CVBC FRM Clients. The position requires the ability to effectively manage multiple projects, perform and evaluate data, generate reports and communicate between internal department and external stakeholders e.g Providers, Health Plans.

ESSENTIAL DUTIESAND RESPONSIBILITIES

Include thefollowing. Others may be assigned.

  • Drive Organizational Success

  • Establishes realistic and aggressive goals,targets, and metrics consistent with strategic and operational objectives(e.g., CMS 5-Star, RAF, IHA P4P measures, MediCal incentive measures, and DHCSoverall quality measures adopted by health plans).

  • Builds consensus and commitment across disparatepeople with often competing priorities. (E.g. internal departments, healthplans, hospitals, contracted physicians).

  • Continually analyzes and interprets performancedata and recommends and/or executes corrective action as needed (e.g.,year-over-year diagnosis reporting, IHA, 5 Star measures, HEDIS quality measurefor all health plans contracted with CVBC FRM clients).

  • ProgramDevelopment and Improvement:

  • Workscollaboratively with Practice leads in conjunction with IPA clients and medicalmanagement teams as well and Reporting and analytics to ensure consistency ofoperations.

  • Oversee analysis and reportingactivities relating to: risk score calculation, claims/encounters datasubmission, chart review programs, IPA performance metrics.

  • Monitor HCCprogram initiatives relative to benchmarks/targets

  • Develop strategic plans by determininggoals, metrics, timeframes and appropriate resources to drive the achievementof improved STARs results, Medi-Cal incentive programs, risk adjustmentprograms and value the contribution of those initiatives

  • OrganizationalPerformance:

  • Oversightof quality in relation to the delivery of medical management services

  • Overseesthe development and support of quality improvement initiatives for CVBC clientsrelated to HEDIS, STARS, RAF, HLL’s and P4P

  • Advise as a key subject matter expertin the organization’s efforts on meeting encounter reportingrequirements. Assist in evaluating issues identified in the encounterdata process related to risk adjustment, and provide input regarding solutionsin order to minimize or eliminate any negative impact to overall qualityperformance across all programs

  • Client Relations:

  • In conjunctionwith the Practice team and Operations, works to ensure that client expectationsare aligned with the contractual commitments and that Quality Improvement executionsmeet the contractual commitments.

  • Leadership andCoaching:

  • Ensuresqualified clinicians are accountable to the organization for decisionsaffecting client’s members

  • Acts as aresource to Sales, Implementation and Practices in relation to the delivery of QualityImprovement Initiatives and tools used by clients to improve overallperformance.

KNOWLEDGE,SKILLS, ABILITIES

Toperform this job successfully, an individual must be able to perform eachessential duty satisfactorily. The requirements listed below are representativeof the knowledge, skill and/or ability required. Reasonable accommodations maybe made to enable individuals with disabilities to perform the essentialfunctions.

  • Advancedknowledge of Medicare, Medicaid and products

  • STARS/HEDISexperience

  • Experienceworking with at risk provider groups and health plans

  • Experience/knowledgeof Federal and State laws, NCQA and URAC regulations relating to managedcare, disease

  • Knowledgeof fiscal management

EDUCATION/ EXPERIENCE

Include minimumeducation, technical training, and/or experience preferred to perform the job.

  • BachelorDegree and 7 years of relevant health plan or

  • Provideroffice medical coding/claims and/or Business Analyst experience in ahealthcare setting applicable to claims/coding, or

  • 10years of relevant health plan or provider office medical coding/claimsand/or Business Analyst experience in a healthcare setting applicable toclaims/coding, in lieu of a degree.

REQUIREDCERTIFICATIONS/LICENSURE

Include minimum certificationrequired to perform the job.

  • 5 years of experience managing across-functional team

  • Proficient knowledge of CMS-HCC model andguidelines

  • Current knowledge of industry audit standardsand in-depth understanding of statistical sampling methods and riskadjustment methodology

  • Coding Certification such as CPC, CCS, CCS-P,RHIT or CRC (Certified Risk Coder) in good standing preferred

  • HEDIS, P4P or Medicare Stars experiencerequired

  • Demonstrated ability to apply criticalthinking skills to coding policy interpretation and implementation.

  • Recent managed care experience with knowledgeof Medicaid, Medicare, and commercial HMO programs.

PHYSICALDEMANDS

Thephysical demands described here are representative of those that must be met byan employee to successfully perform the essential functions of this job. Reasonableaccommodations may be made to enable individuals with disabilities to performthe essential functions.

  • Mustbe able to work in sitting position, use computer and answer telephone

  • Ability to travel

  • Includes ability to walkthrough hospital-based departments across broad campus settings, includingEmergency Department environments

WORK ENVIRONMENT

Thework environment characteristics described here are representative of those anemployee encounters while performing the essential functions of this job.Reasonable accommodations may be made to enable individuals with disabilitiesto perform the essential functions.

  • Office Work Environment

  • Hospital Work Environment

TRAVEL

  • Approximately 25%travel may be required

Job: Conifer Health Solutions

Organization:

Title: Director Quality Improvement (Encino, CA)

Location: TX-Frisco

Requisition ID: 2005028970

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