Resp & Qualifications
PURPOSE:
We are looking for an experienced leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.
This Vice President will drive optimal results for the health plan's Quality, Accreditation, Star Ratings and Risk Adjustment outcomes across all business lines (Medicare Advantage, D-SNP, Medicaid, Commercial/ACA) while providing overall strategic and compliant operations management including effective related vendor partnerships. Oversees and coordinates the development and implementation of all Quality Improvement and Risk Adjustment programs aimed at driving member health improvement for all business lines including achievement of health plan NCQA accreditation demonstrating CareFirst's ability to meet regulatory requirements and standards. Internal expert in pursuit of a minimum 4 Star Rating and the optimization of risk-adjusted revenue for all Government lines of business. Leads the ongoing pursuit of improved performance and continued innovation in ensuring member and beneficiary access to of high quality, coordinated and affordable care.
ESSENTIAL FUNCTIONS:
OVERAL QUALITY AND ACCREDITATION
- Provides overall direction and matrixed leadership of all quality programs. Develop effective quality program improvements and maintains/achieves NCQA accreditation. Establishes solid working relationships with the clinical and operational leaders across the enterprise to ensure the prioritization of and achievement of quality program outcomes and incentives. Provides overall direction to ensure quality programs are provided in accordance with standards established through state and federal regulations, the Center for Medicare and Medicaid Services, and other relevant accreditation agencies. Drives continuous improvement through a holistic and well-run inspection/remediation process and delivery. Responsible for managing accreditation, audits, and required regulatory submissions with a high degree of reliability and compliance. Collaborates with other Blues plans to share and exchange best practices
REVENUE OPTIMIZATION
- Enables optimizing company bonus revenue programs (State Medicaid and Star ratings) across the Government Programs/Medicare portfolio via developing capabilities that support data-driven change in desired member and provider behaviors, process excellence in health plan activities, and improved member health outcomes and experience. Develop and implement ongoing and new efforts to improve member and provider engagement and satisfaction.
RISK ADJUSTMENT
- Directs enterprise strategic and operational prospective and retrospective efforts to optimize risk adjusted revenue and earn bonus payments by integrating capabilities across provider engagement and training, member engagement and experience, health improvement programs, administrative excellence and rigorous data analytics. Identifies and prioritizes risk adjustment opportunities and identifies resources as needed. Leads internal and external risk adjustment data validation.
DATA & REPORTING (RADV)
- Develops analytic and reporting plan and capabilities, organization and governance structure, operationalize and continuously drive results. Collaborates with the data science/analytics and business intelligence teams to determine potential data analytics initiatives with the focus on improving operations to improve risk score accuracy. Collaborates with analytics to develop reporting solutions to measure ongoing performance. Leads the development, analysis and reporting of metrics, as well as oversees analyses of new legislation and regulations regarding and assessing the impact of any changes to the programs. Ensures the timely submission of supplemental data to payers and seeks to automate data flows where possible. Monitors historical and current data trends and CMS notifications related to quality to make recommendations and predictions.
CLOSING GAPS
- Oversees the performance of the person(s) and vendors in charge of chart audits, home visit assessments and the performance of internal resources devoted to the Hierarchical Condition Category/Risk Adjustment Factor (HCC/RAF) efforts. Collaborates with Contracting and Provider Networks teams to drive innovative initiatives that address low performing measures. Oversees outreach strategy and informs the workflows, policies, and procedures that govern engagement with patients that are due or overdue for annual visits and gaps in care. Oversees chart abstraction, patient engagement, and medication adherence team to optimize part D performance.
PROVIDER INCENTIVE PROGRAMS
- Oversees comprehensive provider incentive programs, including some value-based quality performance improvement programs, in cooperation with CareFirst Provider Contracting and Practice Transformation teams. Ensures compliance with and success in value-based care programs quality metrics across all lines of business. Empowers quality improvement leads and practice performance managers to develop comprehensive, practice/provider-specific plans to increase quality performance and improve outcomes.
VENDOR OVERSIGHT
- Leads the evaluation, contracting, implementation, and management of a wide range of vendors that support quality programs.
BUDGET AND HUMAN CAPITAL
- Allocates capital and human resources and establishes operating accountabilities, parameters and priorities. Coordinates interdepartmental programs and drives performance in a matrix environment. Oversees the recruitment, development and retention of effective team members at multiple levels. Completes other enterprise Quality, Stars & Risk Adjustment related assignments as required by Executive Vice President of Health Services.
SUPERVISORY RESPONSIBILITY:
This position manages people.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Business or Clinical related field.
Experience: 12 years experience in a healthcare, public health, health insurance, quality/process improvement or related experience and 7 years of increasingly responsible management experience; or an equivalent combination of education, health care, or health insurance management experience with increasing management responsibilities.
In addition, at least 5 years experience in the oversight of Quality/Accreditation and/or Risk Adjustment programs in a health plan/payor environment.
Preferred Qualifications:
- Experience leading a Healthcare Analytics function in a payor organization.
Knowledge, Skills and Abilities (KSAs)
- Management experience in managed care operations.
- Proven ability to lead with an equal balance of strategic agility and execution rigor.
- Demonstrated leadership effectiveness in both formal and influencer roles; dynamic leader that motivates and inspires teams to achieve challenging targets.
- Must possess superior management, negotiation and analytical skills.
- Requires the ability to develop and maintain strong internal and external relationships and to lead in a matrixed environment.
- Must possess excellent verbal and written communications skills.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $223,840 - $335,760
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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