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.