Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

This position is responsible for leading all aspects of Quality Management Clinical Operations & Audit and Quality Management Performance Reporting, including HEDIS and STARS performance for Horizon Government Programs.

Directs staff to support quality improvement initiatives specifically related to Quality Audit, HEDIS, Stars, and NQCA AccreditationDevelops policies and procedures to support quality improvement initiatives and processesParticipates in special projects as assigned by the Director.Represents the department with internal customers and Sr. Leadership in the event of Director's absenceInterfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.Provide leadership and utilizes professional and communication skills to direct and motivate staff to ensure high quality outcomes.Represents the Plan with external customers, providers and external agencies and represents the unit on corporate issues and/or in the event of Director's absenceManage, direct, and develop staff by providing feedback and coaching. Administer performance, and salary review for staff. Ensure staff meets all regulatory requirements and utilizes best practice methodology.

QM Performance Reporting

Develop annual HEDIS chart review training and administer inter rater reliabilityDevelop HEDIS provider chase strategy to meet Horizons goalsOversees Quality Management compliance of HEDIS chart reviews and overreads.Responsible for development and implementation of HEDIS Roadmap.Develops and implements initiatives to improve HEDIS and Stars performanceManagement and oversight of Horizons Pay for Performance programConduct provider onsite visits to promote and support Pay for Performance programManage relationships and supports external providers to improve HEDIS and Stars performanceCollaborate with Value Based Programs and Provider Contracting and Services to manage provider quality performance.

QM Clinical Operations

Develops and implements strategies for quality improvement and initiatives.Responsible for assuring timely correction of deficiencies, identification of problem providers and promptly reports difficulties or lack of cooperation to the Director of Quality Management.Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.Works with Utilization Management to develop related policies and procedures.

Education/Experience:

Requires a Bachelor's degree from an accredited college or universityRequires five (5) year experience in a healthcare setting: health plan, hospital, physician practice, or managed care organizationRequires a minimum of five (5) years quality management experienceRequires minimum of five (5) years management experienceRequires project management experience.Masters Degree preferredPrefers experience in continuous quality improvement and/or quality management

Additional licensing, certifications, registrations:

Active Unrestricted NJ RN License PreferredActive Unrestricted NJ RN License Required for QM Clinical Operations

Knowledge:

Requires knowledge of HEDIS, CAHPS, and Medicare StarsRequires working knowledge of NCQA accreditation standards.Requires thorough knowledge of managed care productsRequires knowledge of MCO and Horizon BCBSNJ products, services and programs.Requires the ability to think analytically and to use logic in the solving problemsMust be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint & Outlook); Should be knowledgeable in the use of intranet and internet applications.

Skills and Abilities:

Requires excellent verbal and communication skillsRequires strong project management skillsRequires strong organizational skillsRequires strong problem solving and decision making skillsRequires good analytical skills, ability to interpret data to improve quality performanceRequires strong relationship building skills to work collaboratively across departments/divisions

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

$109,600 - $149,625

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.