Director, Medicare Quality and Stars Improvement

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Director of Medicare Quality & Stars Improvement is responsible for developing, leading and executing the quality improvement strategy, optimizing health outcomes and driving improvement in Star Ratings and other quality measures for the Medicare population. The Director will provide oversight and strategic direction to enterprise-wide, cross-functional programs of significant complexity, risk and cost. This person is responsible for comprehensive oversight and success of the Stars program and all activities related to Medicare quality improvement goals and regulatory and compliance requirements. Strategic vision, data-driven decision-making and strong knowledge of Medicare Star program, quality  and quality standards are essential for success.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

• Develops and executes short and long-term Medicare Stars strategy driving improved Star ratings
• Oversees Medicare Stars program performance, including design, implementation and evaluation, with ultimate accountability for achieving corporate and departmental goals
• Designs, implements and leads cross-functional teams to implement continuous quality improvement efforts for all quality measures related to Medicare
• Collaborates across the enterprise with multiple business owners to align on strategy and ensure integrated approach to quality improvement 
• Monitors and analyzes quality performance metrics, including Star ratings, identifying opportunities for improvement and monitoring effectiveness of interventions/programs
• Performs root cause analyses and develops action plans to address performance gaps
• Acts as the CMS Star Measure and Program subject matter expert, advising on quality improvement initiatives and educating across the enterprise
• Enterprise accountability for departmental policies and procedures related to Medicare Quality & Stars
• Communicates effectively across all levels of the organization to promote and culture of quality and continuous improvement
• Maintains vendor relationships and oversees vendor quality improvement activities to ensure all SLAs are being met to achieve organizational quality improvement goals.
• Ensures compliance with CMS regulations and guidance
• Co-leads various regulatory audits to ensure complete and accurate regulatory and compliance reporting.
• Coordinates internal and external reporting requirements with appropriate departments for complete and accurate data reporting.

• Builds a high-performing team that meets departmental and corporate goals, including quality improvement, regulatory compliance, and financial goals

Supervision Exercised:

• Supervises 5-7 clinical and non-clinical staff

Qualifications:
Education:

• Bachelor’s Degree in nursing, health administration or related field required.

Education Preferred/Desirable:

• Master’s Degree in health related field preferred.

Experience:

• 10+ years progressively responsible experience in healthcare quality improvement and leading quality improvement programs
• 5+ years working in a managed care setting
• 5+ years working with Medicare product, including Stars program experience and proven track record of achieving high Medicare Star ratings
• 3+ years prior supervisory/managerial experience

Experience Preferred/Desirable:

• 3-5+ years clinical nursing experience preferred.
• Prior experience with NCQA accreditation highly preferred
• Vendor management experience preferred
• Data/analytics experience preferred
• Program management experience leading large cross-functional programs preferred
  
  
  

Certification or Conditions of Employment: 

• Pre-employment background check
• CPHQ, Lean or green belt certification preferred
• Registered nurse with active license preferred

Competencies, Skills, and Attributes: 

• Outstanding oral and written communication skills; ability to interact within all levels of the organization, influence change and lead cross-functional teams and initiatives
• Strong knowledge of CMS regulations and quality and process improvement methodologies
• Excellent analytical and problem-solving skills
• A strong working knowledge of Microsoft Office products.
• Demonstrated ability to successfully plan, organize and manage projects
• Detail oriented, excellent proof reading and editing skills.
• Highly motivated with the ability to work independently in a fast-paced environment with changing priorities
• Ability to work effectively in a fast-paced, dynamic environment

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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