Accountable for HEDIS related health care quality projects and initiatives through direction setting and leadership. Assimilates information and data integration to proactively develop quality management activities aligned with company strategies and values. Proactively builds strong teams and business relationships, both internally and externally. Serves as a resource and subject matter expert (SME) on regulatory (e.g., DHCS MCAS) and accreditation (e.g., NCQA Medicaid) quality measures of the quality program to develop and influence business strategies.
Manages and influences health care quality projects and initiatives through design, development, and implementation with intent to improve health care quality products, services, and processes. Designs the data collection methodology, target metrics, and data elements needed to measure outcomes of QI projects. Translates and delivers business information to internal and external constituents via formal presentations and/or written communications (e.g. delegates, committees, workgroups, regulators). Develops documentation templates and systems to support QM projects and initiatives. Forms and leads cross functional workgroups to design and implement QI initiatives. May have supervisory responsibilities. Educates and consults with unit business managers on quality improvement methods (e.g., workflow, data analysis, metrics), serving as a technical resource and expert.
Processes and evaluates complex data and information sets related to HEDIS and non-HEDIS quality measures for business needs. Performs quantitative and qualitative data analysis and reaches conclusions about the data. Prepares and completes QM documents based on interpretation and application of business requirements. Assists in the development and implementation of QM projects and QM Work Plan activities (e.g. QM committees, audits, medical record reviews, preventive health and wellness campaigns, etc.). Evaluates and makes recommendations for corrective actions regarding consistent low-quality performance for network providers.
Ensures maintenance of accurate documentation and reporting for quality improvement activities such as HEDIS reporting, surveys, regulatory audits, peer reviews, etc. Directs data collection for HEDIS and/or other quality reporting; identifies opportunities and infrastructure to improve operational efficiency across the organization for improvement based on results. Provides direction for Healthcare Effectiveness Data and Information Set (HEDIS) quality initiatives and regulatory requirements including oversight of outreach to members who are noncompliant in the designated outreach services. Manages effective medical record capture for HEDIS medical record review and abstraction of supplemental data.
Identifies potential resources and initiates collaboration with providers to improve member health outcomes and HEDIS measures. Develops and distributes educational information to members and providers in accordance with the HEDIS outreach work plan (mailings, social media, automated calls, etc.). Assists in the development and standardization of outreach documentation and manages the data flow process to complete HEDIS documentation. \May develop and maintain member incentive programs to support HEDIS initiatives. Maintains incentive database to track member compliance. May identify opportunities to partner with community organizations on special events and presentations (i.e., health fairs and community events). Works with internal staff to schedule, organize, and staff these events. Perform other duties as required.
Bachelor's degree, or other comparable healthcare experience.
5 years clinical and/or managed care experience in the healthcare industry or quality management
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
6+ years progressive experience in operational quality management roles in the healthcare industry, regulatory environment and quality management.
Demonstrated leadership ability.
Previous experience that reflects a proven track record or proficiency in the competencies noted.
Demonstrated verbal/written communication and computer skills.
Ability to work in a fast-paced environment.
Demonstrated ability to plan, organize, and execute multiple functional business objectives.
Previous experience managing staff
Bachelor's degree, or other comparable healthcare experience.
Certified Professional in Health Quality (CPHQ) or other certification a plus
Master’s degree preferred.
Bachelor's degree required or equivalent work experience.
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.