Manager, Quality Management

Overview

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.

We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

• Lead all aspects of Quality Management Clinical Operations & Audit and Quality Management Performance Reporting, including HEDIS and STARS performance for Horizon Government Programs.
• Direct staff to support quality improvement initiatives specifically related to Quality Audit, HEDIS, Stars, and NQCA Accreditation.
• Develop policies and procedures to support quality improvement initiatives and processes.
• Participate in special projects as assigned by the Director.
• Represent the department with internal customers and Senior Leadership in the event of Director's absence.
• Interface with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.
• Provide leadership and utilize professional and communication skills to direct and motivate staff to ensure high quality outcomes.
• Represent the Plan with external customers, providers and external agencies and represent the unit on corporate issues and/or in the event of Director's absence.
• Manage, direct, and develop staff by providing feedback and coaching. Administer performance and salary reviews for staff. Ensure staff meets all regulatory requirements and utilizes best practice methodology.

• Develop annual HEDIS chart review training and administer interrater reliability.
• Develop HEDIS provider chase strategy to meet Horizons goals.
• Oversee Quality Management compliance of HEDIS chart reviews and overreads.
• Responsible for development and implementation of HEDIS Roadmap.
• Develop and implement initiatives to improve HEDIS and Stars performance.
• Manage and oversee Horizons Pay for Performance program.
• Conduct provider onsite visits to promote and support Pay for Performance program.
• Manage relationships and support external providers to improve HEDIS and Stars performance.
• Collaborate with Value Based Programs and Provider Contracting and Services to manage provider quality performance.

• Develop and implement strategies for quality improvement and initiatives.
• Ensure timely correction of deficiencies, identification of problem providers, and promptly reports difficulties or lack of cooperation to the Director of Quality Management.
• Interface with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.
• Work with Utilization Management to develop related policies and procedures.

• Requires a Bachelor's degree from an accredited college or university.
• Requires five (5) years of experience in a healthcare setting: health plan, hospital, physician practice, or managed care organization.
• Requires a minimum of five (5) years quality management experience.
• Requires a minimum of five (5) years management experience.
• Requires project management experience.
• Masters Degree preferred.
• Prefers experience in continuous quality improvement and/or quality management.

• Active Unrestricted NJ RN License Preferred.
• Active Unrestricted NJ RN License Required for QM Clinical Operations.

• Requires knowledge of HEDIS, CAHPS, and Medicare Stars.
• Requires working knowledge of NCQA accreditation standards.
• Requires thorough knowledge of managed care products.
• Requires knowledge of MCO and Horizon BCBSNJ products, services and programs.
• Requires the ability to think analytically and to use logic in solving problems.
• Must be proficient in the use of personal computers and…