Quality Systems Analyst II - Medicare Stars

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Quick Summary

Key Responsibilities

The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

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Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Director of Medicare Stars, the Quality Systems Analyst II – Medicare Stars (QSA II) provides senior support for departmental efforts reinforcing the performance improvement of quality measures impacting HEDIS, MCAS, Medicare Stars, and Health Plan Accreditation. The QSA II is expected to work closely with leadership teams across the organization in support of quality improvement/ transformation initiatives and studies. This position leads the development, preparation and presentation of root cause analytics insights and opportunities. This role builds/iterates low and high-fidelity prototypes to scale insights generation and key recommendations to drive performance. The QSA II conducts proof-of-concept pilots to test and validate recommended solutions. The incumbent manages project deliverables supporting key regulatory deliverables including study development, data collection, data analysis, policy interpretation, policy creation and updates.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

What We Offer

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Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

✓Competitive salary

✓State of the art fitness center on-site

✓Medical Insurance with Dental and Vision

✓Life, short-term, and long-term disability options

✓Career advancement opportunities and professional development

✓Wellness programs that promote a healthy work-life balance

✓Flexible Spending Account – Health Care/Childcare

✓CalPERS retirement

✓457(b) option with a contribution match

✓Paid life insurance for employees

✓Pet care insurance

Responsibilities

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→Serve as Lead Analyst in data collection, analysis, interpretation, reasonability checks, issues reconciliation, presentation of findings to various levels to support transformation projects and ensure the delivered report is accurate, timely, and formatted appropriately

→Understand and interpret data results from various program designs and organize cohesive summaries in presentation formats presented to various audiences including internal and external Committees, The Governing Board, internal and external meetings, other Member and Provider communication methods

→Perform initial data discovery, analysis, and modeling to inform project strategy and operations

→Generate and manage updated case studies of experiments and outcomes within IEHP for reporting and continuous learning

→Demonstrate understanding of department relationships to support the Quality Improvement daily operations. Coordinate among different departmental teams and collaborate with all staff levels to solve analytical issues, documenting results, and methodologies

→Manage assigned projects and effectively communicate between Quality Department and other business units to ensure accuracy, validity, and reliability in support of root cause analytics insights generation on quality measures impacting HEDIS, MCAS, STARS, Covered California, Health Plan Rating, and Health Plan Accreditation Programs. Communicate with Quality Improvement leadership team if any project deadlines are at risk of being met

→Develop key studies and reports and work closely with business owners in support of NCQA Accreditation and other quality compliance standards. These activities include understanding the quality compliance standards, current IEHP business operations, knowledge of available data sources and systems, and appropriate data analysis criteria. Ensure key studies and reports are delivered accurately, timely, meeting compliance requirements

→Maintain updated knowledge of IEHP business operations to be able to appropriately use for Quality Improvement studies, action plans and quality programs. Incorporate LEAN principles into daily work

→Lead efforts in gathering and presenting audit deliverables/requests in support of regulatory requests and audits for the Medicare Stars Quality Improvement team

→Lead efforts in maintaining the Medicare Stars department policies including annual reviews, updates, and ensure that policies are kept accurate and in accordance with applicable regulatory requirements

→Maintain knowledge of current NCQA Health Plan Accreditation Standards and the ability to interpret NCQA communications and changes. Support the Quality Improvement departments in NCQA audit activities, data gathering, and process support as needed

→Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Requirements

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Education & Requirement

A minimum of four (4) years of experience in study development, writing and analysis in a healthcare setting (e.g., quality improvement, patient/provider services, healthcare finance, care management or related fields)
Demonstrated experience working with complex data systems and large data sets
Experience performing online research and working in a team setting
- Prior experience analyzing Medicare Star Measure data and intervention impact preferred
- Demonstrated experience in increasing Plan Star Ratings through targeted quality improvement activities
- Knowledge of Risk Adjustment calculations and financial analysis related to Medicare Advantage membership populations preferred
Bachelor’s degree in biological sciences, public health, health administration, public administration, mathematics, statistics, computer science, or other healthcare related focus from an accredited institution required
- Master’s degree in biological sciences, public health, health administration, public administration, mathematics, statistics, computer science, or other healthcare related focus from an accredited institution preferred
- Project Management Professional (PMP) Certificate, Certified Professional of Healthcare Quality (CPHQ), or other recognized quality improvement certificate required or successful completion within one (1) year of hire

Key Qualifications

Valid California Driver’s License preferred
Advanced knowledge and understanding of:
- Healthcare quality performance and measurement sets (e.g., CMS quality withhold, NCQA Quality Improvement Standards, HEDIS, Medicare Stars, and similar sets)
- Project management techniques, tools of continuous improvement, and work process redesign
- Standardized Quality Improvement concepts
- Standard coding sets and medical terminology as they are used in quality measurement (e.g., ICD-10, CPT, CPT Category II, HCPCS, LOINC, NDC, and similar items)
- Increasing Quality Ratings through targeted quality improvement activities
- Health Plan or Federal, State and Accreditation Requirements
- Provider Workflows, Care Coordination and Transition Management processes
- SDOH, Health Equity, Community Resources, Person-Centered Care, Alternative Care Models
- Managed care claims, payment processes, and insurance terminology
Strongly preferred strong knowledge and understanding of:
- Risk Adjustment calculations and financial analysis related to Medicare Advantage membership populations preferred
- CMS quality programs, Medicare Star Ratings methodology, HEDIS, CAHPS, Pharmacy Part D measures, NCQA standards, Risk Adjustment basics, and regulatory documentation requirements
- Supporting CMS audits, data validation reviews, or compliance reporting
- Medicare Managed Care Manual, HPMS guidance, and CMS regulatory updates.
Advanced proficiency in:
- Reviewing and interpreting regulatory information leading to sound recommendations
- Research, data gathering, data analysis, and visualization tools
- Analytical and critical thinking skills
- All Microsoft Office applications, with an emphasis on Excel, PowerPoint, and Visio
- Communication skills (verbal, written and listening) with ability to interact effectively and demonstrated comfort with public speaking to varied audiences
- Applying facilitation techniques to quality improvement project teams to achieve optimal outcomes
- Problem solving, leadership qualities, conflict management, and team building skills to ensure a productive work environment and achievement of quality goals
- Successfully working with and motivating diverse teams including group process facilitation, change management and conflict resolution
- Teaching quality improvement concepts and principles
Proven ability to:
- Work as part of a cross-functional team and motivate other members in the project team
- Demonstrate a commitment to support the organization’s efforts to become a 5-Star Health Plan and incorporate LEAN principles into daily work
- Be results and outcome oriented
- Perform complex tasks, prioritize multiple projects and work under pressure to meet deadlines in a fast-paced environment
- Demonstrate excellent project management, time management, and organizational capabilities with a high attention to detail
- Work within a dynamic environment, including managing multiple projects, and pivoting or changing direction as needed
- Be results driven, a self-starter, and navigate ambiguity through creativity