At Mount Carmel, we work to continuously inspire one another. Here, all are welcome. It is this culture of humility and compassion that sets Mount Carmel apart. We see the big picture and do the right thing. That means a dedication to the well-being our both our colleagues and the patients they serve.
MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries in Ohio. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.
The Clinical Quality and HEDIS Manager is responsible for coordinating and implementing HEDIS and STAR’s data collection and Medical Record Review process for the Medicare Advantage Plan. This position works in collaboration with the Director of Quality to develop strategies for achieving a 5 STAR rating. Assists with data analysis and report preparation for all required data submissions. Responsible for the day to day operations of the HEDIS field team; provides oversight, direction and support to drive strategies for closing care gaps. Works closely and collaboratively with various functional areas of the health plan to achieve the goals and objectives of the Quality Improvement Program. Manages the Quality RN's that are responsible for investigating Quality of Care/Quality of Service cases.
Responsible for day to day operations of the Quality Department in conjunction with the Quality Director.
Ensures that MediGold meets the CMS and NCQA requirements for HEDIS rate production and required deadlines for HEDIS reporting.
Develop and implement market business plans to motivate providers to engage in improving HEDIS/Star measures to be 4 Stars or higher
Provide analytical interpretation of Star/HEDIS reporting, including executive summaries, to plan and provider groups.
Analyze and evaluate provider group structure and characteristics, operations and personnel to identify the most effective approaches and strategies to close gaps in care.
Responsible for developing and updating policies and procedures based on regulatory and internal process changes.
Prepare MediGold for HEDIS audit and Medical Record Review
Assists the Quality Director with the development of the Quality Management Plan, Work Plan, Strategic Plan and annual summary of the Quality Program.
Hires, trains, evaluates and supervises a staff of HEDIS Coordinators and Quality RN's.
Prepares presentations, training materials, manuals, audit tools and reports as needed.
Actively participates in activities to improve the Plan's Star ratings.
Collaborates with Quality Director to select, monitor and provider vendor oversight.
Presents to internal and external partners about Quality activities and progress.
Advises on matters regarding quality management requirements in the development and implementation of departmental plans or activities
Utilizes clinical knowledge to performs case audits and oversight for Quality of Care/Service and Member Grievances.
Analyzes productivity of nurse reviewers and functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.
All other duties as assigned
Education: Bachelor's Degree in health care field or nursing required or an equivalent combination of experience and education. Licensure/Certification: Valid licensure to practice as a Registered Nurse (RN) in Ohio
3+ years of direct supervisory/leadership experience with direct reports providing on-going evaluation and performance reviews
Strong knowledge of Medicare, HEDIS, Star Ratings, NCQA, CMS, CAHPS & HOS
Project Management experience
Strong relationship building skills with clinical and non-clinical personnel
Strong medical/clinical background that includes; knowledge of medical terminology, anatomy, physiology, medical and nursing diagnoses, reading and interpreting orders, lab values, progress notes, medications and treatment plans to be able to discuss and determine appropriateness of health care provided by various health care provider and partners.
Experience making clear and concise verbal and written presentations to large groups.
Knowledge of performance improvement systems, principles and designs.
Able to set and attain goals without direct continuous oversight and management.
Mount Carmel serves more than a million patients each year. Our more than 10,000 employees and 1,600 physicians utilize state-of-the-art facilities, advanced technologies and the latest procedures to accomplish our mission of healing patients’ minds, bodies and spirits, and improving the health of the communities we serve. We pursue that mission through four hospitals, as well as in outpatient facilities, physicians’ offices, surgery centers, urgent care centers, community outreach sites and home throughout central Ohio. We’re also dedicated to medical education, with six physician residency programs and Ohio’s fourth-largest baccalaureate nursing degree program. Mount Carmel is a member of Trinity Health, a national Catholic healthcare system based in Novi, Michigan.