Director, Performance Improvement
Our Mission: Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.
Inspire health in Arizona as the trusted leader in delivering affordable, innovative healthcare solutions.
Our Benefits: Our benefits provide work-life balance and the flexibility you need to be your best. We offer comprehensive medical, dental, and vision coverage; a 401K savings plan; paid holidays and vacations; and much more!
Position Purpose: The Director of Performance Improvement oversees the training and operations of the performance improvement team in collaboration with other internal stakeholders including, but not limited to Risk Adjustment, Clinical Operations, Network Services, Quality Informatics, Business Intelligence, and Executive Management. The position purpose is to improve the overall quality measure performance of our populations, resulting in better outcomes for our members through analytics and quality reporting.
- Development, coordination, operational management, and monitoring of performance improvement activities related to quality measure Improvement according to AHCCCS and/or CMS / NCQA guidelines and requirements including the development of action plans
- Develops new and evaluates existing quality measure initiatives through workgroups. Implements interventions within the established time frames
- Provides functional support to Clinical Services, Utilization Management, Risk Adjustment, Network Services, Informatics, and Member Experience to integrate quality measure improvement initiatives and goals with organizational programs
- Assists in the presentation and distribution of quality measure data and reporting as well as quality measure improvement best practices throughout the organization and assists with new business opportunities and implementation, including Value-Based Payment initiatives.
- Provides leadership to Performance Improvement Coordinators and direction regarding how to best influence our quality measure performance, including accountability for AHCCCS and Star Rating performance.
- Attends and participates in AHCCCS, Quality and Member Experience related meetings as assigned.
- Provides guidance and direction to Provider Network, particularly Primacy Care Providers, regarding gaps in care for their paneled members and holds them accountable for quality measure performance; provides resources, information and tools to Providers to ensure completion of necessary tasks
- Researches related quality initiatives and regulations through receipt and distribution of periodic NCQA updates
- Measure performance above AHCCCS MPS thresholds and CMS 4 Star Rating cutpoints (HEDIS)
- Proactive planning, organization, and oversight of performance improvement operations, ensuring the highest quality care and services are provided in the most efficient manner.
- Achieve desired outcomes for the performance improvement program operations, strategic implementation and execution of initiatives, cost benefit analysis, and respective overhead expense management.
- Works in collaboration to key stakeholders, large provider group practices and local ACO operations teams.
- Reviews for clinical indicators and query providers to capture the severity of illness of the patient.
- Interacts with providers regarding billing and documentation policies, procedures, and conflicting/ambiguous or non-specific documentation.
- Supports process improvement to enhance physician and staff workflow.
- Supports medical record data review/collection for appeals and exclusions at the time of data submission per contractual obligations.
- Works with Patient Registry and practice Electronic Health Record or paper record to support reporting and monitoring of quality performance and risk adjustment.
- Provide education and guidance for MIPS/QPP/VBP programs.
- Oversee special assignments and projects that support and further organizational initiatives.
- Ensure appropriate reporting on benchmarks to provide timely and relevant information on overall effectiveness of strategic initiatives.
- Oversee the assessment of quality measure performance in relation to established goals and standards, either AHCCCS, CMS, or NCQA.
- Audit quality and risk adjustment reporting as necessary.
- Coordinate with Performance Improvement Coordinators and Supervisors to develop performance improvement plans at the staff and practice level as appropriate.
- Ensures compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines for Risk Adjustment and HEDIS measures.
- Analyze and interpret reporting, execution, and assess efficiency of program initiatives to reach year end targets.
- Anticipate issues, track and trend outcomes, and successfully develop mitigation plans as needed to achieve and/or exceed department and organizational goals.
- Develop and maintain collaborative partnerships with executive management and participate in business development.
- Communicate with Executive Leadership on program progress, status of tasks/initiatives, and process improvement opportunities.
- Provide department support through mentorship, experience, and allocation of additional resources as deemed appropriate and necessary. Build consensus in team environment with the highest level of professional and personal integrity and help foster a positive work environment.
- Assists in preparation of training materials (internal or external).
- Present to key stakeholders, vendors and large groups.
Education / Experience / Other Requirements
Education: (include field of study)
- Bachelor’s degree in related field required (or equivalent combination of education and experience), Master’s degree preferred.
- Medical Assistant certification or LPN license preferred
Years of Experience:
- At least 5-7 years’ healthcare management experience
- Clinical background (Medical Assistant or LPN) with coding (HCC/MRA) experience preferred.
- Experience in quality and risk adjustment.
- General knowledge of Medicaid and Medicare
- General knowledge of health care operations necessary
- Or an equivalent combination of education and experience sufficient to successfully perform the essential duties of this position: 5-7 Years
- Familiarity and understanding of CDPS+Rx and CMS HCC Risk Adjustment coding and data validation requirements, as well as HEDIS.
- Understanding of the health care delivery setting
- Experience with diverse populations a plus
- Must possess the ability to present and explain complex material to organizational leaders, providers and member populations in a professional manner
- Demonstrated performance in project management, process improvement and project implementation
- Proven administrative and coaching ability in complex environments
- Strong ability to analyze, interpret, and evaluate data resulting in actionable recommendations
- Excellent presentation and organizational skills; Excellent oral and written communication skills
- Must have strong problem solving ability
- Ability to prioritize and manage multiple projects and demanding workloads
- Must be able to work in a team environment, with good communication skills, supportive attitude and the ability to provide mentorship when appropriate
- Lean or Six Sigma training a plus; knowledge of process improvement techniques required
- Knowledge of managed care principles and physician practice
- MS Office Suite
- Demonstrated proficiency preparing spreadsheets, graphs and other presentation materials