Blue Cross Blue Shield of Arizona
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HEDIS Program Manager - Medicare Advantage
at Blue Cross Blue Shield of Arizona
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
Purpose of the Job
This highly visible and cross functional role will lead the HEDIS Operational and Improvement Program for the Medicare Advantage Line of Business. The ideal candidate is an exceptional high-level strategic thinker who effectively demonstrates experience and capabilities necessary to advance the year-round HEDIS effort in collaboration with providers and internal health plan resources. The incumbent assures completion of projects in a quality and timely manner, and monitors project activities for adherence to plan and budget. Focused on Clinical and Quality outcomes, this role will partner with Medicare & Medicaid Performance Department staff at BCBSAZ’s Government Markets Program to maximize short- and long- term operational and strategic business activities, ultimately creating valuable solutions to improve the health care system and facilitate growth.
Essential Job Functions & Responsibilities
• Manage activities, resources, methods, and procedures to achieve a successful HEDIS annual event, including implementing best practices to improve HEDIS processes into operations in collaboration with various departments.
• Formulate and ensure compliance with CMS Star and NCQA’s HEDIS technical specifications, policies, operating procedures, and goals. This includes managing and ensuring compliance with the HEDIS Compliance Audit requirements.
• Facilitates collaboration with diverse groups and individuals to influence the implementation of community programming, including design development and evaluation planning, to close care gaps and improve overall health of membership.
• With other key stakeholders, review and implement new technological tools and processes that support HEDIS measure reporting and submission, as well as monitoring improvement efforts while fostering a strong team concept with internal and external stakeholders.
• Collaborates with other leaders and stakeholders to identify, develop, and implement innovative programs and initiatives to improve Star ratings and HEDIS/CAHPS measures.
• Collaborate with internal and external stakeholders to research, analyze, and execute opportunities to educate members and providers as it pertains to Stars, HEDIS, CAHPS.
• Assures timely and accurate data handling, including project file management and submissions to regulatory and accreditation entities for HEDIS measures.
• Provide comprehensive analysis of Star/HEDIS measures, barriers, and opportunities and present results of improvement efforts and ongoing performance measures to Health Plan leadership.
• Subject matter expert on NCQA and HEDIS and CMS Star Technical Specifications
• Develops, maintains, and effectively manages internal and external relationships at all levels across the organization.
• Leads the end-to-end annual HEDIS Operational initiative and the annual HEDIS Compliance Audit.
• Manages relationships and communications with NCQA Account Manager, HEDIS Compliance Auditor, and key vendors critical to the HEDIS and CAHPS annual events.
• Develops and manages project plans that assure action plans are resourced and aligned throughout the HEDIS lifecycle.
• Participates in the development and design of projects, developing procedures, ensuring ease of implementation, designing and developing project work plan, project start up, and setting and meeting project timelines. Assists in identifying resource requirements of assigning projects.
• Assists supervisor in identifying project personnel requirements.
• Serves as an internal subject matter expert on the NCQA HEDIS and CMS Stars technical specifications, including Health Outcomes and CAHPS Surveys.
• Aligns resources to assure accuracy, quality, and validation oversight of any HEDIS supplemental source data, ensuring compliance with NCQA and health plan policies and operating procedures
• Collaborate with other Star/HEDIS team members to establish and manage the external reporting protocols for supplemental data and updates provider partners accordingly on quantitative and qualitative data points. Includes establishing policies and procedures for business rules supporting timely and accurate data submission to and from provider partners.
• Project manages oversight of HEDIS- and CAHPS-related vendors, including timelines for all activities including file submissions are resourced, tracked and delivered on-time and in-budget.
• As needed, identifies risks impacting HEDIS and Star performance, conducting root cause analyses, and facilitating mitigation and resolution plans by working directly with matrix partners and key stakeholders.
• Coordinates regular project meetings to discuss project status, problems, teamwork, etc., and to alert sponsors to problems or risks that may jeopardize project success. Provides recommendations to mitigate. Escalates requests when insurmountable barriers exist.
• Develops or provides project status reports as required or requested. Interfaces with analysts and programmers for data and programming needs. Maintains and monitors project quality monitoring/improvement process.
• Develops project outcome success measures.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.
Within BCBSAZ and HCA, it is essential that we create a culture of inclusion and opportunity as well as actively guard against bias of any kind. Discrimination and racism are real. Our aim is to empower every member of our team to engage in our mission of improving health for Arizonans. We believe that the power and perspective of diversity and inclusion is in fact, essential to our success in serving clients, achieving our mission and creating a healthy environment for all.
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Skill / Requirements
1. Required Work Experience
• 5 years of experience with HEDIS NCQA end-to-end operations, including submissions to accrediting and regulatory entities and supplemental data acquisition, formatting and submission, preferably with Medicare Advantage.
• 3 years of experience with HEDIS/Medicare Star performance measurement, analytics, reporting and forecasting required.
• 6 years of project management experience, including management of large scope and complex projects, preferably in health care/managed care.
• 3 years of experience with process and quality improvement in a managed care environment
• 1 year of Experience working on multiple, competing priorities while demonstrating exceptional interpersonal skills, collaboration and listening skills.
2. Required Education
• High-School Diploma or GED in general field of study.
3. Required Licenses
4. Required Certifications
1. Preferred Work Experience
• 2 years of experience with NCQA Health Plan accreditation process
• 2 years of experience with CMS Star specifications and improvement best practices.
2. Preferred Education
• Bachelor of Art or Bachelor of Science in a health care administration, business, or public health.
3. Preferred Licenses
4. Preferred Certifications
• Certified Professional in Healthcare Quality (CPHQ)
1. Required Job Skills
• Advanced working knowledge of HEDIS technical specifications.
• Demonstrated experience working with data, modeling, and analysis. Knowledge of relational database, spreadsheet, and word processing computer software applications is required.
• Extensive knowledge of health care issues and the health care industry, especially with disease and chronic condition management and improvement strategies.
2. Required Professional Competencies
• Demonstrated ability to find ways to surmount barriers and achieve results despite lack of resources.
• Excellent analytical and problem-solving skills.
• Demonstrated team player who effectively establishes trust with all levels of stakeholders in complex and matrixed environments
• Ability to work independently
• Effectively sees how multiple projects connect and leverages those synergies to add the most value to BCBSAZ.
• Effectively manages multiple projects and prioritizes work based on strategic objectives.
• Exceptional communication, influencing, and teaming skills across all organizational levels required, including presentation experience to leadership teams, clinicians and other stakeholders is required.
3. Required Leadership Experience and Competencies
1. Preferred Job Skills
2. Preferred Professional Competencies
3. Preferred Leadership Experience and Competencies