As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The Director, Quality Improvement is responsible for the implementation and coordination of Health plan Pay of Performance (P4P) Medi-Cal Incentive Program, HCC risk adjustment, Star Program and other Incentive programs for CVBC FRM Clients. The position requires the ability to effectively manage multiple projects, perform and evaluate data, generate reports and communicate between internal department and external stakeholders e.g Providers, Health Plans.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Drive Organizational Success
Establishes realistic and aggressive goals, targets, and metrics consistent with strategic and operational objectives (e.g., CMS 5-Star, RAF, IHA P4P measures, MediCal incentive measures, and DHCS overall quality measures adopted by health plans).
Builds consensus and commitment across disparate people with often competing priorities. (E.g. internal departments, health plans, hospitals, contracted physicians).
Continually analyzes and interprets performance data and recommends and/or executes corrective action as needed (e.g., year-over-year diagnosis reporting, IHA, 5 Star measures, HEDIS quality measure for all health plans contracted with CVBC FRM clients).
Program Development and Improvement:
Works collaboratively with Practice leads in conjunction with IPA clients and medical management teams as well and Reporting and analytics to ensure consistency of operations.
Oversee analysis and reporting activities relating to: risk score calculation, claims/encounters data submission, chart review programs, IPA performance metrics.
Monitor HCC program initiatives relative to benchmarks/targets
Develop strategic plans by determining goals, metrics, timeframes and appropriate resources to drive the achievement of improved STARs results, Medi-Cal incentive programs, risk adjustment programs and value the contribution of those initiatives
Oversight of quality in relation to the delivery of medical management services
Oversees the development and support of quality improvement initiatives for CVBC clients related to HEDIS, STARS, RAF, HLLï¿½s and P4P
Advise as a key subject matter expert in the organizationï¿½s efforts on meeting encounter reporting requirements. Assist in evaluating issues identified in the encounter data process related to risk adjustment, and provide input regarding solutions in order to minimize or eliminate any negative impact to overall quality performance across all programs
In conjunction with the Practice team and Operations, works to ensure that client expectations are aligned with the contractual commitments and that Quality Improvement executions meet the contractual commitments.
Leadership and Coaching:
Ensures qualified clinicians are accountable to the organization for decisions affecting clientï¿½s members
Acts as a resource to Sales, Implementation and Practices in relation to the delivery of Quality Improvement Initiatives and tools used by clients to improve overall performance.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Advanced knowledge of Medicare, Medicaid and products
Experience working with at risk provider groups and health plans
Experience/knowledge of Federal and State laws, NCQA and URAC regulations relating to managed care, disease
Knowledge of fiscal management
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
Bachelor Degree and 7 years of relevant health plan or
Provider office medical coding/claims and/or Business Analyst experience in a healthcare setting applicable to claims/coding, or
10 years of relevant health plan or provider office medical coding/claims and/or Business Analyst experience in a healthcare setting applicable to claims/coding, in lieu of a degree.
Include minimum certification required to perform the job.
5+ years of experience managing a cross-functional team
Proficient knowledge of CMS-HCC model and guidelines
Current knowledge of industry audit standards and in-depth understanding of statistical sampling methods and risk adjustment methodology
Coding Certification such as CPC, CCS, CCS-P, RHIT or CRC (Certified Risk Coder) in good standing preferred
HEDIS, P4P or Medicare Stars experience required
Demonstrated ability to apply critical thinking skills to coding policy interpretation and implementation.
Recent managed care experience with knowledge of Medicaid, Medicare, and commercial HMO programs.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must be able to work in sitting position, use computer and answer telephone
Ability to travel
Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Office Work Environment
Hospital Work Environment
Approximately 25% travel may be required
Job: Conifer Health Solutions
Primary Location: Frisco, Texas
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2005028970
About Conifer Health Solutions
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.