The Quality Manager is responsible for leading key components of the Plan’s Massachusetts (MA) Quality Assessment and Performance Improvement (QAPI) Program including consultation regarding clinical and operational quality improvement initiatives. The Quality Manager is responsible and accountable for clinical quality improvement initiatives which comply with contractual obligations, regulatory requirements and accreditation standards. Provides clinical high-level support for process and operational improvements related to clinical initiatives within the Office of Clinical Affairs.
Ensures the Plan meets contractual, regulatory and accreditation (e.g. EOHHS, EQRO, NCQA, Health Connector, and CMS) requirements for MassHealth Quality Improvement Goals, External Quality Review Organization (EQRO) performance improvement projects, Qualified Health Plan (QHP) Quality Improvement Strategy projects, and related initiatives.
Develops and implements, evaluates and documents interventions related to MassHealth Quality Improvement Goals, MassHealth and Senior Care Options (SCO) EQRO Performance Improvement Projects, and other quality improvement goals/projects.
Develops and documents the Quality Improvement Work Plan and Work Plan Evaluation
Facilitates large multidisciplinary committees and smaller subgroups to create and implement interventions to meet performance improvement project goals.
Generates supporting documentation for new project proposals, including internal and external reports.
Ensures that responses to inquiries from MassHealth, EOHHS, and CMS regarding the Quality Improvement Goals and EQRO are timely and complete.
Responsible for clinical quality related aspects of the SCO Program contract as well as CMS regulatory requirements.
With SCO leadership ensures organizational preparedness to achieve corporate STAR ratings goal. Reports to SCO Steering committee as appropriate.
Works collaboratively with the Quality Program Manager to organize and coordinate the MassHealth Quality Goals and EQRO Performance Improvement Projects including goal design, implementation, tracking, reporting and evaluating overall effectiveness of the initiatives.
Chairs the Massachusetts Quality Committee, a multidisciplinary group, to ensure progress with addressing all opportunities for improvement in regulatory submissions as well as HEDIS performance.
Collaborates with other areas (e.g. Clinical Informatics) to evaluate opportunities for improvement, develop and implement interventions, perform root cause analyses, and recommend appropriate actions to improve clinical and non-clinical outcomes.
Serves as liaison with providers, local educational and clinical agencies to support partnership opportunities developed to enhance the services provided to the Plan members.
Works with Chief Medical Officer (CMO), Senior Leadership and medical directors to achieve corporate quality initiatives.
Responsible for tracking feedback and clinical corrections from providers on condition specific reports and mailings.
Provides clinical support for development, evaluation and revisions to the Plan’s Clinical Registry.
Reviews, investigates and responds to clinical member grievances.
Responsible for review, investigation, tracking, trending and annual reporting of medical adverse events/serious reportable events including follow up and corrective actions in conjunction with the Plan medical directors. Recommends to the CMO cases for non-payment status.
Collaborates with NH Quality staff to develop interventions for QAPI activities.
Responsible for identification, approval, tracking, distribution and reporting of medical Clinical Practice Guidelines.
Works with other areas (e.g. Care Management, Marketing and Communications, Clinical Informatics, Provider Relations) to develop and implement new clinical quality programs including development of program descriptions, assessments, educational materials and interventions.
Reviews and updates identified Clinical Policies and Procedures as assigned
Provides support to the Accreditation Manager for achieving NCQA accreditation for the MA Medicaid and QHP products.
Serves as an organizational resource for quality improvement methodology.
Works to develop systems to collect, analyze, and report quality data.
Other duties as assigned.
Bachelors’ Degree in nursing, health administration or related field required
Registered Nurse with active license
Master’s Degree in health related field preferred
Seven years of experience in progressively responsible healthcare quality improvement experience
Experience working with Medicaid recipients and community services
Experience working in a managed care organization
Experience with NCQA accreditation standards
Required Licensure, Certification or Conditions of Employment:
CPHQ certification strongly preferred
Competencies, Skills, and Attributes:
Effective collaborative and proven process improvement skills
Strong oral and written communication skills; ability to interact within all levels of the organization
Proficient in use of Microsoft Office products
Demonstrated ability to successfully plan, organize and manage projects
Detail oriented, excellent proof reading and editing skills
Working Conditions and Physical Effort:
Ability to work in a fast paced environment
Work is normally performed in a typical interior/office work environment
No or very limited physical effort required. No or very limited exposure to physical risk
Internal Number: 292751
About Boston Medical Center HealthNet Plan
Imagine working for an organization committed to making a difference. Founded in 1997 by Boston Medical Center (BMC), BMC HealthNet Plan supports the mission of BMC by providing medical care access to the underserved, disabled, elderly and other vulnerable populations.
BMC HealthNet Plan is a not-for-profit, market leading managed care organization that offers health insurance coverage to low-to-moderate income individuals in Massachusetts and New Hampshire (where it is known as Well Sense Health Plan). We offer health insurance plans in the Medicaid and commercial markets, and contract with health care providers and hospitals throughout Massachusetts and New Hampshire.
We employ over 600 individuals in Charlestown, Massachusetts and Manchester, New Hampshire. We offer our employees highly competitive benefits, compensation package and flexible work arrangement options. To demonstrate our commitment to serving the community, our employees are entitled to eight hours of paid volunteer time per year.
BMC HealthNet Plan employees are a diverse, talented workforce that work together to represent our values – member focus, stewardship, partnership, quality, inclusion and integrity.