Description
Seeking director / program manager position in the healthcare industry. July 2016 to Present Business Owner - real estate investments marketing and remodeling July 2015 to July 2016 Quality Improvement Project Manager Ohana Wellcare Health Plan, Kapolei, Hawaii WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled. Responsibilities include the development, implementation and marketing of quality improvement interventions and audits and assists in resolving deficiencies that impact plan compliance to regulatory and accreditation standards. Drives key quality improvement projects (including NCQA HEDIS metrics) and quality committees requiring the ability to work effectively in a matrix environment in order to receive needed data that reflects the overall health of the plan. This also involves the developing of project timeline, work flows, best practices for process improvement, and tracking systems to train a high functioning HEDIS project team for annual medical record review. Maintain Quality Improvement Work Plan and Coordination of Care documentation. Tasks include: * Establish and/or revise / edit existing WellCare policies and procedures necessary for successful implementation of the Quality Improvement (QI) Program. * Pursues methods to ensure receipt of relevant data, as required for accurate trending of various QI work plan metrics. * Analyze key plan metrics, such as top diagnoses, clinical procedures, and operational performance, to enable the development of sound and valid recommendations regarding and prioritization of clinical and service improvement initiatives. * Works with QI Director to convene various QI committees and work groups, set agenda to drive desired meeting outcomes (based on contract and accreditation requirements), and ensure proper recording of committee activities. * Act as knowledge expert for continuous quality improvement activities, educating staff of other functional areas regarding the QI process and accreditation requirements. * Perform various quality department functions and processes, such as quality of care complaint/adverse event review and assessment of medical record review results and recommend actions to address any identified improvement opportunities. * Manages and monitor clinical quality studies to include receipt and analysis of trended data, assessment of national benchmarks as available, development of improvement recommendations (to include ROI and best practice interventions as appropriate), presentation to senior leadership, implementation of plan, and evaluation for desired result. * Recommend strategies to improve member compliance to QI program activities, addressing methods to change knowledge, attitudes and behaviors, such as handbook content, newsletter articles, member outreach interventions, and member focus groups. * Recommend methods to improve network provider compliance to health plan QI Program policies and procedures, including profiles/scorecards and efforts to increase provider compliance to practice guidelines, such as through medical record review. * Field annual member and provider satisfaction surveys, working with vendor to clarify results and present findings and recommendations to senior leadership. * Perform activities to comply with annual HEDIS data collection and analysis, preparing recommendations to increase rates as appropriate. * Assist with efforts to secure successful NCQA accreditation and EQRO audits. Monitor and track all state and federal quality improvement and reporting requirements. Support efforts to submit monthly, quarterly, semi-annual, and annual regulatory required performance reports.
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