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 Strategy is responsible for the strategy, 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 develop strategic business plan, 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, HLLâ��s and P4P
Advise as a key subject matter expert in the organizationâ��s 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 conjuction with the Practice team and Operations, works to ensure that client expectations are aligned with the contractural commitments and that Quality Improvement executions meet the contractural commitments.
Leadership and Coaching:
Ensures qualified clinicians are accountable to the organization for decisions affecting clientâ��s 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.
If direct report positions are listed below, the following responsibilities will be performed in accordance with guidelines, policies and procedures and applicable laws. Supervisory responsibilities include interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
Direct Reports: Quality Patient Care Coordinator, Quality Coder Analyst
Indirect Reports: NA
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
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 other healthcare insurance products
STARS/HEDIS experience and/or risk adjustment coding experience from a payer perspective
Experience working with at risk provider groups and healthplans
Experience/knowledge of Federal and State laws, NCQA and URAC regulations relating to managed care, disease
Knowledge of fiscalmanagement
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.
Pharm D, RN or other clinical degree is a plus.
Include minimum certification required to perform the job.
5+ years of experience managing a cross-functional team with prior payer experience strongly preferred
Proficient HEDIS, P4P or Medicare Stars experience
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
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.
Ability to work under minimal supervision and be a self-starter with limited resources
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: Encino, California
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.
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.