UNM Medical Group

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Program Manager, Value Based Care

at UNM Medical Group

Posted: 4/12/2019
Job Reference #: 1591
Keywords: insurance

Job Description

Location:
Office of Managed Care Services-Population Health

Pay Range:
Commensurate with experience

Job Code:
A6010

# of Openings:
1

Job Code/Title: A6010/ Program Manager, Value Based Care
FLSA:  Exempt
Grade: AE14

OPEN UNTIL FILLED

UNM Medical Group, Inc. (UNMMG) is the practice plan organization for physicians and other medical providers associated with the UNM Health Sciences Center. UNM Medical Group, Inc. is a New Mexico non-profit corporation and is an equal opportunity employer. UNMMG offers a competitive salary and an attractive benefit package which includes medical, dental, vision, and life insurance as well as tuition assistance, paid leave and 403b retirement for benefits eligible employees.

Supports and assists in establishing Population Health Quality Initiatives for Federal Quality Programs and Value Based Care within the Health System.  Works with Population Health area to assist in planning and coordinating STARS, HEDIS, Meaningful Use/Promoting Interoperability, Merit Based Incentive Program (MIPS), and NCQA compliance and preparation activities in support of Population Health Management contracts, including Medicare Fee-for-Service, Medicare Advantage, Medicaid Managed Care, and commercial lines of business.

The following statements are intended to describe, in broad terms, the general functions and responsibility levels characteristic of positions assigned to this classification. They should not be viewed as an exhaustive list of the specific duties and prerequisites applicable to individual positions that have been so classified.

Summary

Under the direction of the Director, HS Population Health, VBC, this position is responsible for supporting and assisting in establishing Population Health Quality initiatives for Federal Quality Programs, and Value Based Care within the Health System.  Works with Population Health directors to assist in planning and coordinating STARS, HEDIS, Meaningful Use/Promoting Interoperability, Merit Based Incentive Program (MIPS), and NCQA compliance and preparation activities in support of Population Health Management contracts, including Medicare Fee-for-Service, Medicare Advantage, Medicaid Managed Care, and commercial lines of business.  Responsible for identifying opportunities for improvement and staff education on STAR initiatives, to include HEDIS, and CAHPS surveys as it relates to improving member experience and health outcomes.  Conducts Population Health quality quarterly medical record audits and abstract of HEDIS/STAR measures through medical record review and according to current NCQA specifications.  Oversees eCQMs (CMS’s Electronic Clinical Quality Measures) configuration, reporting and validation.                                                                                    

Duties and Responsibilities

  1. Manage annual and ongoing HEDIS & STARs initiatives.
  2. Provide expert level review of submitted Annual Wellness Visit notes; identify gaps in clinical documentation that require clarification for accurate code assignment.
  3. Evaluate documentation to ensure that diagnosis coding is supported and meets specificity requirement to support clinical indicators, HEDIS and STARS quality measures including validation of ICD code submissions for accuracy and compliance with Risk Adjustment documentation standards.
  4. Work with payor and provider teams to ensure HCC clinical documentation requirements are met, and quality performance targets are met annually.
  5. Analyze coding quality review outcomes and develop formal written performance reports on a quarterly basis, with target of 95% accuracy.
  6. Meet with PCMH Unit and Medical Directors and deliver educational feedback sessions to include review of quality outcomes and performance, and identify areas of opportunity for improvement.
  7. Develop relationships with clinical providers and communicate coding and documentation guidelines and requirements of the Risk Adjustment program to ensure accuracy and specificity.
  8. Work closely with Federal Quality program team to ensure accurate configuration, documentation and submission of reports for UH, SRMC and Medical Group.
  9. Project quality scores annually and develop improvement programs to achieve targets.
  10. Support Director, Value-Based Care, to develop and implement strategies related to Value-Based Quality Improvement, HEDIS, STARS, VBC and P4P Programs as well as assessing the HS’s quality and performance, including supporting HS audits related to contractual documentation review.
  11. Analyze and trend clinical and provider performance data to develop strategies and interventions to meet contractual value-based targets and goals, including HEDIS, STARS, Risk Adjustment, HCC documentation and P4P Program performance.
  12. Partner with HS Practice Leads regarding QI activities to assure collaboration of efforts to close gaps in care and provide reporting to facilitate that process.
  13. Develop and maintain monthly performance dashboards.
  14. Facilitate, track and reconcile flow of contractually required data and documentation to managed care organizations, from PCMH sites, that demonstrates compliance for VBC contracting.
  15. Works collaboratively with IT, data analysts, and other clinical users to support the design, development, evaluation, validation and implementation of data analysis tools to track, monitor, and report outcomes and progress toward goals.Interprets results and identifies opportunities for improvements.
  16. Performs other related duties and responsibilities as required or assigned.

Minimum Job Requirements

Bachelor’s Degree in a relevant field, with five (5) years directly related experience preferable in a large medical group or healthcare system.  Experience in clinical coding, population health management and quality, risk adjustment/HCC, provider documentation auditing, and process improvement/educator role preferred.  Verification of education and licensure will be required if selected for hire.

Knowledge, Skills and Abilities Required

  • Knowledge of Medicare and Medicaid Federal Quality programs
  • Knowledge of HEDIS, STARS, VBC, P4P, HCC and RAF
  • Maintain a working knowledge of applicable federal laws and regulations related to VBC. Ability to work with clinic informatics and EHR technology, clinical documentation, and auditing tools.
  • Ability to effectively communicate with physicians and staff.
  • Skill in the development of policy and procedure documentation.
  • Knowledge of CMS regulations and understanding of potential areas of risk for fraud and abuse in regards to coding and documentation.
  • Ability to analyze, interpret, and draw inferences from research findings, and prepare reports.Must have information research skills.
  • Ability to communicate effectively, both orally and in writing with all levels of the organization.
  • Organizing and coordinating skills.
  • Understand challenges and concepts of CMS Quality Rating System in order to successfully implement.
  • Knowledge of published HEDIS and Stars technical specifications.
  • Understand Supplemental data concepts for HEDIS.

Conditions of Employment

  • Must be employment eligible as verified by the U.S. Dept. of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA).
  • Must pass a pre-employment criminal background check.
  • Fingerprinting, and subsequent clearance, is required.
  • Must provide proof of varicella & MMR immunity or obtain vaccinations within 90 days of employment.
  • Must obtain annual influenza vaccination.
  • If this position is assigned to a clinical area, successful candidate will be required to complete a pre-placement medical evaluation/health screen.  Required N-95 mask fitting, testing, vaccinations to include annual TST, Tdap, and Hepatitis B will be determined based on location and nature of position.

Working Conditions and Physical Effort

  • Work is performed in an interior medical/clinical environment.
  • No or very limited exposure to physical risk.
  • No or very limited physical effort required.

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