The Manager, Quality Improvement and Data Science is responsible for the implementation and coordination of Conifer VBC Quality Program and Risk Adjustment for Financial Risk Management (FRM) clients. The scope of work include improving quality of care and optimizing risk adjustment revenue across Conifer IPAs through daily monitoring and operations of Health Plan Pay for Performance (P4P) Incentive Program, HCC risk adjustment, HEDIS, CMS STARS and other quality improvement and risk adjustment programs. The position requires the ability to design and conduct in-depth analytics and research to support quality improvement and risk adjustment programs and to provide oversight of program processes and outcomes to effectively manage multiple projects and initiatives across Conifer IPAs, ensure analytic rigor in report generation and evalution of programs and initiatives and communicate complex risk adjustment and quality improvement concepts, strategies, analytics, initiatives and results between internal department and external stakeholders (e.g Providers, Health Plans, Conifer Leadership)
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
% of Time
Drive Organizational Quality Program Success
Drive actions to meet quality 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).
Build consensus and commitment across disparate people/stakeholders with often competing priorities. (e.g. internal departments, health plans, hospitals, contracted physicians).
Analyze complex data and information to provide meaningful results, identify success factors and improvement opportunities, suggest potential solutions, and help internal customers set strategic directions.
Supervise the QI production team to continually analyze and interpret performance data and recommend and/or execute 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).
Keep abreast of current and new business content, regulatory knowledge, best practices, analytical methods and knowledge of diverse data sources-and systems necessary to support the efforts of QI and Risk Adjustment analytics initiatives.
Drive HCC Program Development and Improvement
Work collaboratively with Practice leads in conjunction with IPA clients and medical management teams as well and Conifer Reporting and Analytics to ensure consistency of operations. Use business intelligence, analytic, and data science techniques to improve risk adjustment results, including obtaining data from various internal and external sources, designing and structuring files for analysis and performing and interpreting descriptive, bivariate, and multivariate analyses. Leads the development of risk adjustment program analytics to address key strategic problems such as the accurate identification of members for gap closure and quality improvement opportunities
Oversee risk adjustment analytics 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
Oversight of quality in relation to the delivery of medical management services
Oversee the development and support of quality improvement initiatives for CVBC clients related to HEDIS, STARS, RAF, and P4P
Advise as a key subject matter expert in the organizationâ��s efforts on meeting encounter reporting requirements. Evaluate issues identified in the encounter data process related to risk adjustment and quality, and provide input regarding solutions in order to minimize or eliminate any negative impact to overall quality performance across all programs
Develop and manage relationships with other analytic teams and leaders at Conifer to share best practices across the organization
Provide leadership with information to answer the question of whether we are focused on the right members, the right types of gaps in coding and care, how much we have improved the accuracy and completeness of diagnostic and service data, what opportunities remain, and estimate the value of those opportunities to drive risk adjustment and quality strategy and mitigate risk
Attend health plansâ�� workgroups and JOMs, and clientâ��s quarterly QI committee meetings
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 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 (titles)
QI Business Analyst, Quality Patient Care Coordinator, Quality Coder Analyst
Indirect Reports (titles)
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.
Minimum of four years of progressive experience in healthcare or risk adjustment data analysis required
Experience modeling data involving outcomes and utilization, using various statistical software and computer programming (SAS, SQL, R, etc.) required
Demonstrated ability to evaluate quantitative data from multiple sources using statistical analysis and critical thinking skills required
Demonstrated experience with statistical software suites (e.g., SAS, R, Stata), strong understanding of database structure, relational database concepts
Must have experience with programming in SQL, ETL, Azure Data Factory or similar Data Warehouse technologies
Deep expertise (3-5 years) in data warehouse and data mart development, data integration techniques, star/dimensional schemas. Hands-on expertise in developing ETL based programs across heterogeneous sources and targets
Must have previous project implementations building analytical environments where they can demonstrate expertise engaging with business and technical stakeholders, document functional and technical requirements, build and read source to target mapping documents, develop and test the ETL routines, and support user acceptance testing
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 health plans
Experience/knowledge of Federal and State laws, NCQA and URAC regulations relating to managed care, disease
Knowledge of fiscal management
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.
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
Bachelor Degree and 3-5 years of relevant health plan or provider experience required.
Masterâ��s Degree in Public Health, Business Administration, or relevant field, preferred
3-5 years experience in leading quality program or risk adjustment operations from either health plans or provider systems.
Minimum of four years of progressive experience in healthcare quality and risk adjustment data analysis required.
Previous experience managing a cross-functional team (including front-line staff) strongly preferred
Familiarity with health policy, health insurance, benefit plans and product features, provider contracting approaches, reimbursement approaches and health management approaches required.
Demonstrated strong organizational and project management skills, including the ability to handle multiple concurrent assignments, required.
Experience programming using risk adjustment models for Medicare, computing risk scores and evaluation of risk scores output for quality preferred. Prior experience in risk adjustment activities in a Medicare, Affordable Care Act or provider organization to including submission of Risk Adjustment Processing System (RAPS), and (Encounter Data Processing System (EDPS), responses and reconciliation per CMS and other State and Federal Guidelines preferred.
Knowledge of claims coding and payment methodology, associated with a Health Plan domain preferred. Background in CPT, HCPCS, and related Hierarchical Condition Coding (HCC) methodologies preferred
Proficient HEDIS, P4P or Medicare Stars experience
Proficient knowledge of CMS-HCC model and guidelines
Ability to work under minimal supervision and be a self-starter with limited resources
Include minimum certification required to perform the job.
Coding Certification such as CPC, CCS, CCS-P, RHIT or CRC (Certified Risk Coder) in good standing preferred
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
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.