Job Description

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

PURPOSE OF THE JOB

This position, with minimal supervision, is responsible the efficient operation of all processes designed to improve Centers for Medicare and Medicaid Services (CMS) Star program. This position will manage the technical, business and clinical operations of Medicare Star Program with interface with Medical Management, Quality Management and Care Management departments.  This position is also responsible for maintaining an effective, collaborative working and oversight relationship with provider partner organizations engaged in these processes to develop quality improvement strategy, tactics and division of responsibility.  This position works closely with analytics resources to develop and maintain accurate reporting and analysis regarding star measures.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

  • 5 years of progressive experience in Risk adjustment, HEDIS, or Star Rating Program leadership with a track record of successful Retrospective Chart Retrieval metrics.
  • 3 years of experience managing the end-to-end NCQA and supplemental data submission process either through a vendor or with internal staff; Position manages the relationship with Blue Advantage’s certified NCQA auditor.
  • 1 year of experience in SQL
  • 2 years of experience managing HEDIS, CAHPS, and HOS surveys including oversampling and case-mix adjustment analysis.
  • 1 year of experience in project management with demonstrable results.
  • 3 years of experience working with health care data.

Required Education

  • Bachelor of Arts or Bachelor of Science degree required;

Required Licenses

  • N/A

Required Certifications

  • N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

  • 5 years of Experience supporting mid-level or large Medicare Advantage plans with a third-party vendor or consultant on HEDIS, STARS, Coding, Provider engagement or Claims strategy.
  • 3 years of experience managing the end-to-end HEDIS submission process either through a vendor or with internal staff.
  • 3 years of experience presenting provider engagement and HEDIS/STARS strategy including program launch and overviews to C-Level executives; Proven documentation of HEDIS and Medical Record Retrieval strategy implementation.
  • 1 year of experience managing an in-house chart retrieval coding team and subsequent processes for hybrid measures and Medical Record Review.
  • 3 years of experience supervising nursing staff.

Preferred Education

  • Master’s Degree in Health Care, Business Administration, Biostatistics or Nursing.

Preferred Licenses

  • N/A

Preferred Certifications

  • N/A

 

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

  • Collaboration with provider partner organizations to develop uniform processes to deliver care gap information to providers of care. Ordinates the receipt and quality of all supplemental data sources for provider partners in Maricopa and Pima County.
  • Serves as a subject matter expert for CMS updates for STAR Measures and their cut-points; Provides insight and analysis on trends for proactive strategies at entity and provider level.
  • Collaborates with provider partner organizations  C-Level executive team to develop overall HEDIS/STAR roadmaps and identify audit protocols for NCQA submission process.
  • Works with internal and vendor-based analytic platforms to identify opportunities for improvement, gap closure and facilitates efforts to implement processes and process changes to promote positive advances.
  • Create and maintain tracking and reporting system that documents key performance metrics and provides mechanism for evaluation of activities coordination and effectiveness related to the STAR Program.
  • Develops and maintains relationships with provider partner organizations  Medical directors to develop short and long-term strategies on the advancement of STAR Measures and interventions for non-compliant membership.
  • Creates presentations and/or reports for senior management involving significant analysis of multiple or complex data sources; Chairs STAR initiative meetings at joint operating committees in Maricopa and Pima county markets.
  • Provides education and support to providers and third-party administrators as needed to accomplish project goals and objectives.
  • Participate in the Quality and Chronic Condition Improvement Programs as a subject matter expert on longitudinal research driven outcomes.
  • Manages vendor portfolio for analytics, HEDIS and STAR Programs.  Negotiates ideal contracts and service level agreements for Blue Advantage; holds vendors accountable for overall performance and maintains scorecards.
  • Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.
  • Provides all customers with an excellent service experience by consistently demonstrating our core behaviors each day.
  • The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
  • Perform all other duties as assigned.

COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

  • Knowledge of Microsoft Office Products - Word, Access, Excel, PowerPoint.
  • Competency in Project Management.
  • Proficient in Excel and fundamental database management.
  • Good communication skills.

Required Professional Competencies

  • Advanced skill set in database management via Microsoft or Electronic Health Records experience such as (Cerner, Centricity, or EPIC); must be able to query for data driven trends that impact STAR Ratings.
  • Strong organizational skills, as well as, good oral and written communication.
  • Experience working with IT Teams and biostatisticians to develop projections on gap closure rates, medication adherence, STAR Ratings and CMS trends.
  • Working knowledge of RAPS, EDPS process measures/requirements.
  • Good understanding of statistics as relates to health care.

Required Leadership Experience and Competencies

  • N/A

PREFERRED COMPETENCIES

Preferred Job Skills

  • N/A

Preferred Professional Competencies

  • Advanced skill set in SQL or SAS; Ability to query of large vendor-based HEDIS and STARS platforms.

Preferred Leadership Experience and Competencies

  • N/A

Our Commitment

AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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