Quality Management Consultant

US-IA-Des Moines
Job ID
212675
Category
Clinical/Provider Support
Requires Non-Compete?
No

Job Summary

Wellmark is hiring a Quality Management Consultant to coordinate and support quality management (QM), accreditation and compliance activities. This individual will manage core processes and QM activities in an effort to support member health improvement, successful HEDIS submissions, and assuring compliance with regulatory rules and accreditation standards. Additionally, this individual will serve as a resource and subject matter expert to all levels within the organization on QM, HEDIS and compliance activities.

 

This particular opening will ensure organizational compliance with NCQA, state, and federal requirements, along with internal policies and procedures; with a focus on HEDIS. The incumbent will develop program material, manage the completion and delivery of program documents according to strict timelines, work closely with internal business partners and external stakeholders and manage the HEDIS submission process. Prior experience is desired in the areas of NCQA and HEDIS standards and accreditation, identification and execution of best practices, and/or proven experience in program management that resulted in high performance outcomes.

 

Core Competencies:

  • Accountability: Owning and taking responsibility for one’s actions.
  • Business Acumen: Understanding industry, market, financial and company specific operations.
  • Collaboration and Communication: Working together; listen to other’s ideas; communicate accurately and concisely.
  • Decision Making: Consider all facts and impacts when making decisions.
  • Focus on the Customer: Consistently doing what is in the best interest of our customer. Leaving a positive impression on the customer by elevating their experience; making it simpler and educating to helping them understand.

Minimum Qualifications Required (all must be met to be considered)

Bachelor's Degree or direct and applicable work experience.

  • 4+ years of work experience in a utilization management, quality management, accreditation coordination, or related role from within a clinical, health care delivery, managed care, or similar setting.
  • 1+ year of health insurance operations or related industry experience, including exposure to quality assurance principles or techniques.
  • Ability to review standards, business policies and procedures, health care literature, and/or medical cases. Must be able to draw defensible conclusions from available information.
  • Knowledgeable in regulatory standard or regulation review – e.g. URAC, NCQA, accreditation standards, confidentiality, state/federally mandated processes, etc.
  • Excellent analytical, diagnostic problem solving skills. Strong attention to detail and the ability to identify, research, and analyze issues, organize information, and make appropriate decisions. Ability to view the “big picture” when making decisions.
  • Demonstrated success in roles that require strong time management and workflow management skills. Ability to prioritize effectively and manage multiple projects.
  • Strong written and verbal communication skills with the ability to communicate and/or present complex information to stakeholders. Ability to negotiate if needed.
  • Proficiency with Microsoft Office applications, specifically Excel. Ability to run reports, construct documents, organize data, etc.



 

Hiring Specifications Preferred

  • Master's Degree.
  • Active and unrestricted RN license in Iowa or South Dakota.
  • CPHQ certification.
  • HEDIS experience.

 

 

Job Accountabilities

a. Provide coordination for the Wellmark HEDIS measurement process and ensure adherence to audit standards and technical specifications. Provide oversight of the contracted Certified HEDIS Software vendor, and independent HEDIS Auditor. Work collaboratively with Vendor representatives and Auditor in the development and execution of business relationships and improving the HEDIS process.

b. Educate and engage Wellmark internal and external stakeholders on quality management QM, accreditation, HEDIS and compliance activities. This includes fully informing all appropriate Wellmark staff and appropriate owners of processes of accreditation and compliance requirements, and what specifically is required to stay compliant with said standards. Offer solutions and expertise in the process of compliancy.

c. Comply with regulatory standards, accreditation standards and internal guidelines remain current and consistent with the standards pertinent to the Quality Management team.

d. Assist in the support of assigned accreditation/audit functions during onsite surveys.

e. Participate and provide leadership written information on gaps in Wellmark performance and associated risks to accreditation. The written communication includes recommendations and potential process improvements for work processes.

f. Identify and implement QM initiatives that promote the delivery of appropriate identified care, coordinated to preserve member benefit dollars as well as improving member health status, and member satisfaction with Wellmark.

g. Measure Wellmark QM metrics with adherence to audit standards and technical specifications. Provide critical quantitative and qualitative analysis, identify opportunities for improvement identified and implement with subsequent measurement and analysis of the interventions that equip Wellmark, members and providers to manage the health care of our members, or internal processes or policies. This includes support of the annual HEDIS reporting process.

h. Develop QM programs, institute work plans, evaluate and report findings to the appropriate governing bodies at required intervals.

i. Provide support of the Wellmark QM Committee Structure. Manage relationships with external committee members. Attend and or provide staff support of assigned committees.

j. Thoroughly investigate all H&CM member and provider complaints. Provide support to Medical Staff through the management of the Quality of Care and Service Quality Complaints process. Aggregate and analyze data and provide reporting to Medical Team and the QOC on said complaints.

k. Provide critical quantitative and qualitative analysis, identify opportunities for improvement and implementation with subsequent measurement and analysis of the interventions that equip members and providers to manage the health care of our members.

l. Provide support to the H & CM leadership team by interacting with Wellmark corporate compliance team to assess H & CM impacts from state and federal regulatory requirements, and BCBSA mandates. This includes maintaining the compliance matrix specific to H & CM, and communicating to leaders when new or existing compliance activities need assessed or completed. This includes supporting the Business Continuity Planning and preparation process.

m. Other duties as assigned.

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