Blue Cross Blue Shield of Massachusetts Sr. Quality & Compliance Program Manager (R01639) in Quincy, Massachusetts

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As a valued member of the Quality and Compliance team, the Sr. Program Manager will contribute to numerous cross functional projects. These projects include Case management program design in compliance with NCQA accreditation standards, implementing new accreditation requirements, preparing documentation for accreditation submission, monitoring through chart review risks and other opportunities for improvement with clinical program and accreditation compliance. This includes working through influence and as an individual contributor and collaborating with other departments, external delegates, and team members to lead/support corporate initiatives. The Program Manager's focus may include case management, provider and vendor delegation oversight, and other quality/ compliance work.

Responsibilities:

The Senior Program Manager, Quality and Compliance is responsible for NCQA standards; including:

  • Evaluate NCQA compliance and collaborate with operations to drive improvement

  • Standing up new standards

  • Monitors ongoing compliance and identifying opportunities for improvement

  • Document and communicate risk analysis to all levels of the organization

  • Project manage and coordinate accreditation and compliance activities; related to population heath and case management.

  • Keep project leads and Senior Manager informed of key issues, risks, timetables, and project milestones

  • Perform delegation oversight activities in accordance with NCQA standards and BCBSMA standards

  • Work with Senior Manager and Senior Program Managers to identify/ implement workflows and process improvements to maximize quality, efficiency and cost effectiveness of team

  • Is expected to share expertise, with all HMM associates through educational opportunities, job shadowing, and to improve QI culture and skills within HMM

  • Is able to matrix and leverage relationships within HMM and outside business partners (PMI, Medicare Ops/Compliance, Network/Contracting) on advancing quality improvement goals and accreditation/CMS needs in Q & C

  • Support organizational commitment to quality, engage stakeholders, provide consultation support to QI structure and committees, evaluate and integrate quality innovations, promote population health approach, utilize evidence based best practices when developing programs and measures, lead and facilitate change.

  • Other responsibilities as identified by the Senior Manager

Qualifications (Knowledge, skills and abilities):

  • Experience in Quality Management and QI techniques and theory

  • Strong understanding of clinical quality improvement principles and ability to creatively link these principles to the development and implementation of collaborative quality initiatives

  • Demonstrated ability to review data and reports, connect with business leads on what the data shows, and support analysis of the results to goal and identify opportunities/interventions for improvement with the business

  • Experience working with NCQA accreditation requirements/ standards knowledge including Case Management and CM auditing experience

  • Demonstrated leadership skills and experience, including consensus building, negotiation, meeting facilitation, and the ability to manage change

  • Must be able to manage all aspects of multiple projects simultaneously from conceptualization through development, implementation and evaluation.

  • Ability to work in a matrixed environment with multiple departments and vendors and coordinate all functions to achieve timely project development and completion

  • Strong organization and time management skills including the ability to meet deadlines, problem solve, and manage multiple competing priorities

  • Knowledge of JIVA/and or care management information systems and care management processes

Experience and Education:

  • RN or clinical professional degree with active Massachusetts license (clinical) with 5+ years clinical experience or in a managed care environment

  • 3-5 years’ experience working with relevant NCQA Standards, CMS compliance or other quality improvement/compliance management or demonstrates competencies of the position and has successfully prepared for and completed essential components of the role such as third party audits.

  • Master’s degree preferred

    OR
  • Bachelor’s degree required; Advanced degree preferred (i.e. business or health administration) or applicable certification (Quality, Compliance, Project management)

  • 3+ years’ experience in managed care, quality improvement, or compliance experience required

  • 3-5 years’ experience working with relevant NCQA Standards, CMS compliance or other quality improvement/compliance management or demonstrates competencies of the position and has successfully prepared for and completed essential components of the role such as third party audits

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LocationQuincyTime TypeFull time

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.