Job Details

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

The Quality Improvement Department is committed to assessing current systems and processes to ensure the continuous improvement and regulatory compliance of overall health service delivery. This position is responsible for identifying, implementing, and overseeing projects relating to quality improvement/compliance initiatives in one or more of the following primary areas: -CMS Five-Star Rating System and the Quality Rating System (QRS) -Marketplace Exchange Quality Rating Systems (QRS) -NCQA Accreditation and state regulatory compliance -HEDIS

ESSENTIAL RESPONSIBILITIES

• Thoroughly reviews data, trends, and best practices to identify projects and approaches toward achieving excellence in area(s) of focus, including regulatory compliance, a 4 to 5 Star Rating in the CMS STAR Rating System, a 4 to 5 star rating in the QRS Rating System, and compliance with NCQA Accreditation standards and guidelines.

• Leads focused workgroups to identify areas of improvement, develop and implement QI strategies, and ensure compliance with regulatory/accreditation bodies. Tracks progress and coordinates recommendations from workgroup members. Reports progress and workgroup recommendations to leadership and appropriate committees, and progress on initiatives to the Quality Management Committee.

• Interfaces and coordinates efforts with various departments/vendors/contracted partners to develop and implement strategies that will address overall quality improvement, ensure compliance with regulatory requirements (NCQA, HEDIS, CMS, DOH, QRS), and align with corporate priorities.

• May serve as primary contact for the organization with regulatory bodies as it relates to reporting requirements and quality management/improvement/assurance.

• Participates in BlueCross and BlueShield Association Quality workgroups.

• Coordination of annual review of corporate administrative policies and procedures related to quality, accreditation and regulatory compliance.

• Manages projects and initiatives within the area of Health Care Quality Improvement & Reporting as needed.

• Other duties as assigned or requested.

EXPERIENCE

Required

• 5 years of healthcare-related work experience

• 3 years of experience managing projects

Preferred

• 3 years of experience in accreditation and regulation

SKILLS

• Knowledge of care management, managed care, health insurance industry, and the provider community. For Accreditation & Regulatory focus, thorough knowledge of DOH and CMS regulations and the reporting requirement components.

• Excellent verbal and written communication skills

• Ability to work effectively and manage multiple projects with minimal supervision

• High degree of business maturity and demonstrated confidentiality

• Strong organizational and leadership skills with the ability to manage multiple conflicting priorities

• Demonstrated personal accountability

• Excels in a team environment

• Project management or process improvement experience

• MS Word, Excel, PowerPoint

• Strong presentation skills

• Knowledge of Medicare processes/systems is a plus

EDUCATION

Required

• Bachelor's degree in business administration or healthcare administration or relevant experience and/or education as determined by the company in lieu of bachelor's degree.

Preferred

• Masters degree in business administration or healthcare administration

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• None

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office- or Remote-based

Teaches / trains others

Occasionally

Travel from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$57,700.00

Pay Range Maximum:

$107,800.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.

For accommodation requests, please contact HR Services Online at ...@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req ID: J273833