AVP, Health Plan Quality & Risk Adjustment (Nevada)

JOB DESCRIPTION Job Summary

Provides strategy and leadership to team responsible for health plan risk and quality activities. Oversees health plan execution for risk and quality, including alignment with enterprise quality strategy. Interfaces with regulatory agencies, leads local quality committees, and oversees and executes local intervention activities designed to improve quality measures and outcomes. Collaborates with corporate quality teams to facilitate data collection, reporting and monitoring for key quality performance measurement activities, and National Committee for Quality Assurance (NCQA) accreditation surveys and federal and state quality improvement (QI) compliance activities. Leads local execution/support for Medicare Stars strategies and performance improvement.

Essential Job Duties

• Provides strategy development, vision and direction for the health plan risk and quality function. Ensures alignment with corporate risk and quality solutions strategy and activities. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised.
• Represents as a key stakeholder in collaboration with the corporate risk and quality team to plan and implement evidence-based quality intervention strategies and initiatives that meet state and federal intervention rules, in alignment with established best practices related to quality.
• Serves as operations and implementation lead for local execution of Molina plan quality improvement activities, and leverages a defined roadmap, timeline and key performance indicators (KPIs) for risk and quality initiatives.
• Aligns with enterprise quality strategy on the design, implementation, and monitoring of the effectiveness of a comprehensive risk and quality intervention strategy, and represents as a critical stakeholder in establishing the strategic direction from the interventions Joint Operations Committee (JOC).
• Serves as primary contact to state agencies for all risk and quality matters.
• Leads the local health plan quality committees.
• Prepares, in collaboration and support with the corporate quality team, required documentation for state performance improvement projects.
• Collaborates with the corporate risk and quality solutions teams to develop, deploy and evaluate risk and quality intervention strategies.
• Collaborates with the corporate quality team on National Committee on Quality Assurance (NCQA) accreditation activities.
• Communicates with leadership on quality-related key deliverables, timelines, barriers and escalated issues.
• Partners with the corporate risk and quality solutions and health plan network leaders/teams to support establishing QI benchmarks and requirements for value-based care (VBC) contracts.
• Partners with corporate risk and quality solutions and Medicare Stars leadership to develop the local Medicare Stars work plan, and execute on interventions designed to improve Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS), and Health Outcomes Survey (HOS) scores.
• Monitors Medicare Part D and operational health insurance metrics, and coordinates with centralized teams on improvement strategies.
• Partners corporate risk and quality solutions and Medicare Stars leadership in managing Medicare-Medicaid Plan (MMP) quality withhold revenue; supports development of interventions and a local strategy to improve withhold revenue earned to meet or exceed budgeted goals.
• Collaborates with corporate risk and quality solutions on broad-based quality data analytics needs/reporting.
• Oversees local health plan clinical data acquisition resources supporting required VBC customized reports to meet VBC network contract obligations not supported by the corporate team.
• Presents summaries, key takeaways and action steps about Molina risk and quality strategy at national and health plan meetings; leads and influences cross-functional teams that oversee implementation of risk and quality interventions.
• Represents as local leader for intervention execution, and partners with corporate risk and quality solutions for qualitative and quantitative analysis, expected return on investment (ROI) analysis, KPI development, reporting and program materials, and templates or policies.
• Represents as a member of the health plan provider engagement team for large, contracted, value-based provider systems.
• Attends state and regional QI and/or Board of Directors (BOD) meetings and representing the health plan.
• Represents Molina in external forums, presents Molina's risk and quality results, and serves as the external risk and quality expert and emissary in statewide conferences and collaboratives.
• Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of quality/department-specific goals.
• Develops and sustains a high-performance team, dedicated to best in class solutions; responsible for attracting, developing and retaining top-tier talent to support strategy and long-term business objectives.

Required Qualifications

• At least 10 years experience in quality improvement (QI)/compliance/HEDIS operations in a managed care setting, or equivalent combination of relevant education and experience.
• At least 5 years management/leadership experience.
• Advanced knowledge of the quality discipline, including metrics and performance standards.
• Knowledge and experience related to risk adjustment.
• Ability to think strategically, develop vision, and execute effectively and efficiently for both near term and long-term results.
• Experience implementing effective quality interventions and performance measures that drive change and support business objectives.
• Experience educating network providers to develop effective practice-based quality improvements and advance value-based quality initiatives.
• Advanced knowledge and experience related to HEDIS, NCQA, CAPHS, and Medicare Stars.
• Proficiency with data analysis, manipulation, interpretation and reporting.
• Critical-thinking, problem-solving and analytical skills.
• Attention to detail and organizational skills.
• Ability to work cross-collaboratively in a highly matrixed organization.
• Project management experience.
• Excellent verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Experience in quality/risk adjustment leadership role with a managed care payer supporting all lines of business (Medicaid, Medicare, Marketplace).
• Advanced risk adjustment experience.
• Advanced experience working with providers on value-based initiatives.
• Advanced experience developing quality improvement (QI) initiatives/measures.
• Deep knowledge and experience related to HEDIS, NCQA, CAPHS, and Medicare Stars.
• Certified Professional in Healthcare Quality (CPHQ).
• Registered Nurse (RN). If licensed, license must be active and unrestricted in state of practice.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V