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Medicare Performance Improvement Lead

Job Ref: 57556
Category: Quality Assurance
Department: QUALITY MANAGEMENT
Location: 160 Water St. #3, New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $85,000.00
Salary Range: $85,000.00 - $93,000.00

Marketing Statement

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview 

The primary function of the Medicare Performance Improvement Lead is to provide leadership in developing, implementing, monitoring and coordinating quality improvement initiatives that support the goal of improving Medicare Part C Operational measures. This position will work directly and collaboratively with all MetroPlus departments, regulatory agencies and with Provider Groups/Facilities to achieve Plan goals for improving Medicare Star measure performance.  This position will serve as the subject matter expert for Medicare Star Operational measures.

Job Description

  • Design, implement and evaluate complex quality and process improvement projects required to support Star and regulatory needs to drive specific operation quality improvement outcomes. 70%
  • Research, develop and identify internal and external barriers/root causes that affect that impact poor operational performance and ensure that implementation of strategies to overcome these barriers.
  • Develop methods and /or tools to collect and track barriers for targeted process improvement.  Methods may include but not be limited to surveys, focus groups, observation, work flow analysis, process mapping, time and motion studies, etc. 
  • Create plans/interventions based on barrier, data, and/or competitor analysis, defined project scope and goals, measurable metrics for program evaluations, and projected timelines.
  • Develop communications that are clear, direct and actionable.
  • Apply analytics to identify and target various sub processes to drive quality improvement and measurable outcomes
  • Evaluate interventions for project/intervention continuation and/or modification to provide for continuous process improvement.
  • Develop tools and supports for external and internal stakeholders relative to measures/desired outcomes to drive continuous improvement. 
  • Document findings for each initiative and present results to applicable departments and management.
  • Lead and/or participate in external activities, work group or committees promoting improvement and goals.
  • Participate in relevant committees and work groups; make presentations, prepare reports, data or other materials for committee presentation.
  • Implement monitoring processes designed to hold the gains.  This includes but is not limited to designing training material, procedures, process control plans, etc. designed to identify process changes for corrective actions.  
  • Analyze organizational data for specified measures to identify trend and target area for quality improvement projects.  Data sources and tools may include but not be limited to the following:
    • Statistical significant changes in rates/stratifications.
    • Data from members, providers, internal processes owners, vendors, regulatory reports and datasets and internal databases.
  • Coordination and implementation of corporate Quality Improvement initiatives including Chronic Care Improvement Projects (CCIP) and Quality Improvement Projects (QIP) for Medicare Advantage, including Special Needs Plans (SNP) and Medicaid programs.
    • Track progress, provide project status reports and presents key metrics and actions plans to the Director of Medicare Stars
    •  Effectively manages internal communications by collaborating and disseminating project activities and outcomes to impacted departments.
    • Identify actions required to improve performance and works with impacted departments to drive implementation and improve results. 
    • Complete annual QIP and CCIP templates and/or attestations per CMS requirements.
  • Support the CCIP and QIP annual CMS submission process to ensure timeliness and compliance. 
  • Actively lead other departments to coordinate and meet measure improvement needs/goals.  Participate in identification of best practice benchmarks in relation to operational process measures.   Align resources utilizing maximum effectiveness and efficiency. 15%
  • Develop and maintain positive working business relationships with community organizations, pharmaceutical vendors, behavioral health vendors, labs, provider groups, regulatory agencies and others to promote the continuous improvement of Metro Plus’s operational processes that impact Part C and D Operational Star measures. 
  • Participate in various Health Educational events. 15%

Minimum Qualifications

  • Bachelor’s degree in analytical field including Finance, Health Care Management or related field.  Master’s Degree a plus.
  • Five to eight years’ experience in any analytic field.  Two to three years of managed care experience preferred.
  • Understanding of CAHPS measures and knowledge of HEDIS, QARR, Star reporting processes strongly preferred
  • Knowledge of quality improvement activities such as PDSA preferred.
  • Must have strong working knowledge of Microsoft Office applications including Word, Excel, Access and PowerPoint.
  • Experience with relational 
  •  Ability to lead others on large scale, complex, highly visible projects.
  • Superior working knowledge of MS Office applications.
  • Solid analytical skills paired with strong attention to detail.  Uses rigorous logic and methods to solve difficult problems with effective solutions.  
  • Excellent verbal and written communication skills.
  • Knowledge of health care data systems.
  • Learns quickly when facing new problems, a relentless and versatile learner.
  • Flexible and adaptable in a rapidly changing environment.
  • Ability to generate new and unique solutions and makes connections among previously unrelated notions.
  • Dedicated to meeting the expectations and requirements of internal and external customers
  • Creates a climate in which people want to do their best, can motivate team or project members.
  • Ability to shift gears comfortably, can decide and act without having the total picture.
  • Steps up to conflicts, seeing them as opportunities, can find common ground and get cooperation with minimum noise.
  • Ability to figure out the processes necessary to get the job done, knows what to measure and how to measure it. 

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication