Summary
Oversees direct coaching support to a physician/provider practices to make improvements in systems and delivery of care. Ensures establishment and maintenance of excellent relationships with network hospitals, physician and/or designated practices, and their representatives. Leads activities related to outreach and coaching support to designated practices. Leads project quality measurement, reporting, audit materials and communication activities. Plans detailed special projects focused on Quality Improvement (QI) and Risk Adjustment activities. Provides direct coaching to practices as needed, and/or will work in partnership with any existing practice or health system QI coaches (where they exist) to build QI capacity within practices to meet improvement goals.
Description
Position Purpose
The Provider Quality and Risk Adjustment Manager, Medicare Advantage oversees direct coaching support to a physician/provider practices to make improvements in systems and delivery of care. In this critical role, you will ensure the establishment and maintenance of excellent relationships with network hospitals, physician and/or designated practices, and their representatives. You will lead activities related to outreach and coaching support to designated practices. You will also lead project quality measurement, reporting, audit materials and communication activities. In this leadership role, you will provide direct coaching to practices as needed, and/or will work in partnership with any existing practice or health system QI coaches (where they exist) to build QI capacity within practices to meet improvement goals.
What You’ll Do:
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Ensures establishment and maintenance of excellent relationships with provider organizations. Leads activities related to outreach and serves as liaison to provider organizations and physician practices for assigned programs. Assures compliance with established quality program standards. Coaches practices in the collection and management of relevant program data. Analyzes trends regarding practice performance to inform coaching plans and opportunities for shared learning events. Prepares and submits various reports to management. Works with other relevant provider organizations and statewide groups, as applicable, to coordinate and align quality improvement efforts.
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Plans detailed special projects and leads project planning teams and workgroups using various continuous QI tools and methodologies. Recommends courses of action to management in the development and completion of special projects, audits and policies. Develops and maintains workflows using quality and process improvement skills. Supports integration with other related initiatives. Identifies and facilitates opportunities to integrate project with other QI initiatives. Develops and disseminates relevant project materials, communications, surveys, etc.
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Provides direct practice facilitation and QI coaching to practice teams, ongoing training, consultation and monitoring to facilitate practice redesign and/or other QI improvements for designated practices. Provides support to existing practice coaches where those exist with ultimate goal of developing QI capacity of practice team to make improvements in practice operations and/or clinical quality.
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Develops relationships and works with consumer organizations as appropriate. Identifies and shares best practices through webinars, website and/or QI learning sessions. Stays abreast of new developments and industry trends related to best practices in clinical QI and practice transformation. Creates educational materials (webinars, brochures, etc.) for providers and conducts provider training as needed. Makes presentations to individuals and groups as indicated.
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Ensures appropriate communication with key stakeholders. Works with health program staff to create and update web-based communications and information. Contributes to health programs and project communications as appropriate.
To Qualify for This Position, You’ll Need:
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Bachelor's degree in any major. OR Associate's degree and two (2) years of work related experience OR four (4) years of work related experience.
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6 years of healthcare system management, quality improvement, risk adjustment, provider network, health claims management or a combination of these.
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2 years’ experience with direct health programs. 2 years project coordination experience. Leadership experience. (all may be concurrent).
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Knowledge/understanding of automated medical management systems and claims processing systems.
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Experience in health care office environment with demonstrated responsibility for process improvement and quality improvement.
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Knowledge of quality improvement concepts, and ability to learn models and methods including clinical practice transformation models and methods.
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Excellent verbal communication and presentation skills.
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Ability to demonstrate excellent writing and written communication skills.
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Excellent relationship management skills.
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Ability to work independently and to collaborate with teams of individuals in diverse settings, with solution-oriented approach.
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Good judgment.
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Strong leadership skills.
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Demonstrated customer service and organizational skills.
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Ability to persuade, negotiate, or influence others.
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Analytical or critical thinking skills.
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Ability to handle confidential or sensitive information with discretion.
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Working knowledge of project management tools.
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Ability to travel up to 30%.
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Microsoft Office.
We Prefer That You Have:
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Bachelors degree in Nursing, or a healthcare related field
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Certified Professional Coder License. ( AAPC )
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At least 1 year leadership experience.
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Medicare Advantage or Fee-for-Service (FFS) operations and/or compliance experience.
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Experience in Provider Relations, HEDIS, STARS,
What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have access and opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
Our comprehensive benefits package includes:
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401(k) retirement savings plan with company match
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Health Insurance
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Free vision coverage
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Voluntary dental, vision, and life insurance
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Paid annual leave — the longer you work here, the more you earn
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Nine paid holidays
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On-site cafeterias and fitness centers in major locations
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Wellness programs and a healthy lifestyle premium discount
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Tuition assistance
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Service recognition
What to Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify with prioritization given to those candidates who demonstrate the preferred qualifications.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail abilities@bcbssc.com or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.