ED, Program Management and Oversight, Medicare

The ED, Program Management and Oversight, Medicare is responsible for coordinating and monitoring quality initiatives. This role serves as a connection point across the organization and enterprise functions related to overall Medicare quality. An ability to lead people across a matrix through influence (and not through organization design) is an essential capability for this leader. This role will be responsible for achieving Medicare STARS and Quality program outcomes including business goals across departments, functions or regions. 

The ideal candidate will:

• Have extensive experience in STARS and related business processes and complex program management. 


• Have demonstrated experience leading a quality improvement program in accordance with the strategic goals of the health plan.


• Partner with market and enterprise leadership to implement a quality improvement program in accordance with the strategic goals of the health plan


• Collaborate with leadership to develop and implement processes to measure and collect data for HEDIS/Stars leading and lagging indicators.


• Analyze and identify trends to develop improvement strategies and action plans for quality rating systems (HEDIS, QRS, Stars) across all lines of business.


• Engage market and health plan leadership on HEDIS/STARS strategy, make recommendations to address areas of concern and provide status on projected results.


• Monitor to accomplish timely submission of HEDIS/Stars program data submissions (i.e. CAHPS, HOS, HEDIS)


• Identify and resolve risks related to quality processes and data gaps.


• Closely follow CMS guidelines and translate into business strategies and tactics. 


• In-depth familiarity with Medicare and Government Programs, including STARS, Lines of Business (LoBs), and comprehensive knowledge of regulatory and compliance standards across different markets, including Medicare, Medicare Advantage, Affordable Care Act (ACA) Marketplace, Commercial plans and Medicaid. 

Oversees the program team, holding the team and team members accountable for results. Proactively monitors, identifies and mitigates risks, issues and trigger events within and across multiple interdependent programs by leveraging expertise and implementing changes. Oversees compliance of program activities by ensuring program plans and team members adhere to relevant policies and procedures. Oversees the alignment, buy-in, engagement and support of diverse program stakeholders. Champions the standards for vendor performance, provides direction for service improvements, and directs partnerships and contract negotiations with vendors.

• Develop and implement a quality oversight program for government programs such as Medicare STARS and Medicaid that establishes effective oversight and provides support for performance improvement. 


• Leads national initiatives focusing improving quality, affordability and member satisfaction for Medicare and patient vulnerable populations 


• Directs analytical activities to monitor performance against quality and operational goals and to deeply understand the nuances of each Medicare program (MA, Duals, DSNP) segment and market, and measure performance of interventions


• Identifies market-specific priorities and determines the appropriate strategic approaches to drive STARS performance


• Proactively collaborates with key Health Plan and market leaders at the regional level to support the delivery of quality initiatives.


• Responsible for quality oversight of external network contracts.


• Serve as a subject matter expert on managed care quality


• Ensures strategic learnings are incorporated in business decisions and system-wide priorities that support the growth 


• Promote a culture of innovation, professional growth and organizational collaboration.


• Empower teams to achieve goals and align priorities as needed


• Provide strategic direction for data and measurement, leverage data to drive decision-making and program improvements 


• Complex Initiatives Management:
  
  
  
  • Oversee the delivery of large-scale programs or strategic initiatives with multiple workstreams and strategic business goals across departments, or functions with responsibility and accountability for achieving program outcomes from an initiation to close-out. 
  
  
  • Develop key performance metrics, milestones, specifications, documentation and reporting requirements and budgets. 
  
  
  • Collaborate with internal stakeholders to ensure work is aligned with business operations to advance priorities and critical path milestones. 
  
  
  • Oversee financial forecasting, implementation planning, operating model accountabilities and strategic market analysis.
  
  
  • Buildout process for financial modeling, reporting and forecasting, closely tied to operational performance of a given initiative, develop strategies collaboratively to drive performance, mitigate risk and realize opportunity.
  
  
  • Ensure all contracting activities comply with healthcare regulations and ethical standards
  
  
  
  


• Monitor all CMS and market-specific requirements to ensure compliance with federal and state regulations and implement business process changes to comply with changes in regulatory requirements


• Communicates with senior Medicare leadership to provide updates, escalate issues, report on milestones, and give visibility on critical next steps. 


• Tracks year over year process improvement through collaboration with reporting and analytics teams and drives initiatives to increase program accuracy and quality. 


• Regulatory Knowledge: In-depth familiarity with various value-based care programs, Lines of Business (LoBs), and comprehensive knowledge of regulatory and compliance standards across different markets, including Medicare, Medicare Advantage, Affordable Care Act (ACA) Marketplace, Commercial plans and Medicaid