job

About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The Quality Improvement Program Manager is responsible for developing and executing a strategy to improve the quality performance for Santa Clara Family Health Plan. This role serves as a critical resource and subject matter expert in supporting, monitoring, managing, and driving strategic projects, interventions, and initiatives for the organization’s Medicaid quality improvement program.

This is a highly collaborative role that partners with internal teams across the company, external vendors, and healthcare providers to ensure our programs are achieving our goals. The role uses a variety of data sources to determine performance across current and emerging NCQA Healthcare Effectiveness Data Information Set (HEDIS) & Medi-Cal Accountability Set for Health Care Delivery System (MCAS) measures, identify insights and opportunities for performance improvements, and share these findings with stakeholders to drive continuous improvement.

This position reviews and accurately interprets complex regulatory documents, including HEDIS & MCAS measure specifications from CMS and DHCS and measure stewards. This position will lead and present material at internal and external meetings, develop and conduct training on HEDIS & MCAS-related topics, assist in regulatory comment development, help drive goal setting, help prioritize interventions, and develop/implement Quality Improvement Health Equity Transformation Program (QIHETP) documents and initiatives related to quality.

Day to Day:

Implement strategies and initiatives on the HEDIS & MCAS work plan, including managing projects of varying degrees of complexity (i.e., administration of DHCS surveys, Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey, multi-channel member outreach, provider education, off-cycle surveys, and prescription drug event reconciliation).

Independently produce and manage prospective quality reports with analysis to manage program performance, support rating predictions, and support meetings with delegates, provider groups, and internal stakeholders.

Interpret and organize information around current performance, historical trends, predicted performance, and opportunities for improvement (including opportunities relative to competing plans in the market).

Provide comprehensive analysis of measures, barriers, and opportunities, and present results of improvement efforts and ongoing performance measures to management.

Serve as a subject matter expert (SME) on HEDIS & MCAS measures, including the measures that apply to each contract and the organization’s strategy for achieving the highest possible rating for each contract, and reviewing regulatory communications and staying abreast of changes to QI program rules, measures, and/or measure specifications.

Manage current quality initiatives, collaborate and educate SCFHP staff, provider network and community partners on how to improve SCFHP QIHET Program.

Manage regulatory deliverables, including but not limited to: Population Needs Assessment, Quality Improvement Projects, Performance Improvement Projects, Strengths Weaknesses Opportunities & Threats, Plan Do Study Act.

Implement and support NCQA Accreditation and DHCS Quality & Health Equity activities, including but not limited to: CalAIM, Population Health Management (PHM) initiatives, Health Equity, Social Determinants of Health(SDOH).

About You:

Bachelor’s Degree in Public Health, Healthcare, or a related field, or equivalent experience.

Minimum of three years of experience with quality improvement in health-related setting, including performing root cause analysis, Plan Do Study Act methodology and monitoring/analyzing improvement, program development.

Knowledge of Medicaid principles and practices with emphasis in quality improvement.

Proven ability to design and execute strategic plans for continuous improvement initiatives.
HEDIS experience.

Medicaid plan or ACOs experience.

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