Job Description

Clinical Quality Manager Summary

The Clinical Quality Manager with members and providers to ensure members receive appropriate services. This role researches, compiles, and analyzes appropriate and relevant clinical quality data to identify opportunities to recommend and drive execution of process efficiencies in assigned business units to achieve targeted levels of improvement in key operational HEDIS performance and Value-based care metrics. This role emphasizes improving the quality of care with a focus on HEDIS measures, value-based care and population health strategies. 

Supervision Received 

The Clinical Quality Manager reports to the Chief Operations Officer (COO) and collaborates closely with the Director of Clinical Operations and team. 

Job Responsibilities 

• Serve as HEDIS clinical subject matter expert in supporting measure improvement initiative design and annual audit across multiple clinics.

• Responsible for leading clinical HEDIS communications with internal and external parties demonstrating expertise in technical specifications and application in clinical settings
• Interacts with clinics, providers, and members to improve quality of care, monitor progress, and recommend changes

• Reviews billing codes, medical records, and claims submission process to ensure accuracy
• Attends and facilitates any initiative meetings (studies, partnerships) that involve targeted providers and/or measures.
• Completes on-site visits on a regular basis to implement the work plan and to conduct provider education sessions regarding appropriate coding practices and chart documentation.
• Collaborates with other departments to maximize member outreach for preventive services and chronic disease management.
• Oversees all performance-based contracts, including Pay-For-Performance, HEDIS, and Value-based Contracts
• Meets regularly with insurance payors to monitor performance in population-based arrangements
• Supports regulatory affairs, as deemed necessary by management.
• Documents all relevant interactions in appropriate system
• Additional duties as assigned

Minimum Qualifications:

• Bachelor’s Degree
• Two years’ experience in healthcare quality-related position

Preferred Qualifications:

• Master’s Degree
• Clinical license: LPN, RN, LMSW or LCSW
• Multiple years of HEDIS review experience for both Medicaid and Medicare lines of business
• Medical record review experience directly working on HEDIS in a managed care setting
• Intermediate MS Word, Excel, and PowerPoint

Skills/Knowledge/Abilities Required:

• Strong knowledge of HEDIS technical specifications. NCQA audit requirements and clinical application of HEDIS quality measures
• Ability to work under general direction.
• Ability to work effectively in a team environment.
• Excellent analytical, organizational, planning, verbal, and written communication skills.
• Other related skills and/or abilities may be required to perform this job.
• Ability to write routine reports and correspondence. Ability to speak effectively before internal and external stakeholders of the organization.
• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
• Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.
• Ability to work with and empower others on a collaborative basis to ensure success of unit team.
• Ability to effectively exchange information, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions, and employing active listening techniques.
• Ability to effectively present budgetary and/or cost information and respond to questions as appropriate.
• Ability to establish workflows, manage multiple projects, and meet necessary deadlines.