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Manager, Clinical Quality Improvement

VNS Health
paid time off, tuition reimbursement
United States, New York, New York
220 East 42nd Street (Show on map)
Mar 12, 2025

OverviewLeads the clinical audit team and oversees quality improvement initiatives with a primary focus on Medicare STARS and clinical program performance for VNS Health Plan. Ensures regulatory compliance with CMS and DOH standards, collaborates with IPAs and provider networks, and drives quality outcomes through provider education, member engagement, and audit oversight. This role will be the primary clinical point of contact for STARS and quality initiatives while supporting strategic goals to optimize quality ratings and performance metrics. Implements, monitors, and evaluates quality improvement strategies based on national benchmark data to achieve top decile performance. Analyzes performance and recommends improvement initiatives and/or corrective actions. Utilizes a quality improvement framework, such as Six Sigma - Define, Measure, Analyze, Improve and Control or Plan, Do, Study, Act, to facilitate rapid cycle improvement strategies. Serves as a consultative resource to quality improvement committees and work groups. Integrates compliance and regulatory requirements into QI processes. Works under general direction.
What We Provide
  • Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
  • Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
  • Employer-matched retirement saving funds
  • Personal and financial wellness programs
  • Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
  • Generous tuition reimbursement for qualifying degrees
  • Opportunities for professional growth and career advancement
  • Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
  • Referral bonus opportunities

What You Will Do

  • Leads the clinical audit team, ensuring compliance with Medicare STARS, HEDIS/QARR, and regulatory requirements.
  • Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient/member case review, including the design, testing and evaluation of the review methodology.
  • Oversees the quality review process, including the monitoring of provider and IPA performance to drive improvements in clinical quality and outcomes.
  • Conducts provider education and training sessions on coding accuracy, documentation, and quality reporting to improve STARS and HEDIS scores.
  • Acts as the primary clinical liaison for IPAs and provider networks, ensuring alignment with STARS, HEDIS, and clinical quality objectives.
  • Works closely with IPAs and provider networks to optimize care coordination and member experience, addressing gaps in quality performance.
  • Implements and refines audit methodologies to assess compliance with clinical quality standards and regulatory expectations.
  • Collaborates with Quality leadership in the development of action plans based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies.
  • Investigates patient related complaints and quality of care (QOC) issues, incidents, and serious adverse reportable events in collaboration with internal staff and providers. Performs focused and comprehensive quality assessment reviews; identifies and analyzes results; prepares investigation summary reports; and creates/implements corrective action plan as appropriate. Analyzes data sets for trends and formulates opportunities for improvement based on those trends. Provides education about identified quality trends, outcomes of reviews and new requirements.
  • Follows-up to ensure corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.
  • Analyzes and reports quality data trends to leadership, identifying key opportunities for intervention and process improvements. Coaches, facilitates and monitors continuous improvement to attain strategic quality objectives and industry benchmarks for patient/member outcomes, satisfaction, cost and regulatory requirements.
  • Supports CMS compliance and audit readiness, ensuring accurate and timely data submissions. Participates in the coordination, review, revision and approval of policies an d procedures for Provider Services. Identifies gaps and recommends creation of new policies.
  • Develops and oversees corrective action plans for identified deficiencies, tracking progress and impact on STARS performance.
  • Prepares for CMS and regulatory site visits, ensuring compliance with Medicare Advantage quality reporting standards. Participates in the preparation for and assists with site visits of outside surveyors/regulators for the purpose of regulatory compliance and accreditation.
  • Partners with the education team to implement training programs for providers and care teams on STARS, HEDIS documentation, and best practices. Collaborates with Education department in the development of and implementation of quality related training programs and/or corrective action training related to identified deficiencies.
  • Leads and/or participates on quality improvement committees and projects related to performance improvement, measurement and documentation.
  • Keeps informed of the latest internal and external issues and trends in quality management through select committee participation, networking, professional memberships in related organizations, attendance at conferences/seminars and select journal readership. Revises/develops processes, policies and procedures to address these trends.
  • Assists with analysis of member satisfaction surveys and audits including but not limited to the CMS Health Outcomes Survey, Consumer Assessment of Health Care Providers and Systems (CAHPS) or internal satisfaction surveys. Collaborates with Health plan staff to develop initiatives and action plans to improve member satisfaction.
  • Participates in the development and implementation of quality projects and initiatives across all product lines, including but not limited to NCQA HEDIS, SNP Structure and Process, Quality Scorecard, IPRO Projects, and CMS Quality Projects.
  • Performs all duties inherent in a managerial role, including hiring, training, developing, recommending salary actions and when necessary, terminating staff.
  • Participates in special projects and performs other duties as assigned.
Qualifications

Licenses and Certifications:

  • License and current registration to practice as a Registered Professional Nurse or Licensed Clinical Social Worker LCSW) in New York State required
  • Certified Professional in Healthcare Quality (CPHQ) or similar certification preferred

Education:

  • Bachelor's Degree in Nursing or a related healthcare field (e.g. LCSW) required
  • Master's Degree in Nursing equivalent experience in Quality Management will be considered preferred

Work Experience:

  • Minimum of five years of healthcare quality improvement experience, with a focus on Medicare STARS, HEDIS/QARR, and clinical audits required
  • Knowledge of health care delivery systems, patient care, care coordination, and clinical processes required
  • Experience leading quality audits and regulatory reporting in a managed care setting required
  • Experience working with provider networks, IPAs, and clinical teams to drive quality initiatives required
  • Experience in EMR navigation such as EPIC or HCHBStrong knowledge of CMS Medicare Advantage STARS program, NCQA, HEDIS, and QARR requirements required
  • Excellent oral, written and interpersonal communication skills required
  • Knowledge of basic Performance Improvement tools and methodologies required
  • Proficiency in Word, Excel and PowerPoint required
Compensation$98,200.00 - $130,800.00 Annual About Us VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us-we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 "neighbors" who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.
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