Manager, Provider Quality Management - Remote

EmblemHealth; New York (NY); Remote; USD 80,000 - 110,000; Full time

Job summary

An established industry player is seeking a Manager for Provider Quality Management to lead quality improvement initiatives across its network. This role involves collaborating with cross-functional teams to enhance clinical performance and ensure compliance with regulatory standards. The ideal candidate will have a strong background in healthcare, data analysis, and quality improvement methodologies. Join this forward-thinking organization to make a significant impact on public health and provider quality while managing a dedicated team to achieve optimal outcomes.

Qualifications

• 5-8+ years of experience in healthcare, preferably managed care.
• Knowledge of relational databases and statistical analysis.

Responsibilities

• Support quality improvement processes across all regions.
• Analyze quality-related data for clinical and administrative service studies.

Skills

Data Analysis

Quality Improvement Methodologies (PDSA, DMAIC)

Analytical Skills

Staff Management

Process Management

Knowledge of HEDIS, QARR, CAHPS, HOS

Education

Bachelor’s Degree in Health Services

Advanced Degree

Tools

MS Access

Job description

Manager, Provider Quality Management - Remote

Identify, develop, execute, evaluate, and oversee quality and process improvement projects to support public health, HEDIS, QARR, NCQA, and other regulatory quality measures for our network providers. Develop and monitor Quality Improvement metrics in collaboration with department leadership to ensure sustained gains and corrective actions, supporting compliance with HEDIS, QARR, and Star processes across all regions with membership. Drive and monitor clinical performance with vendor activities to enhance the quality data set. Collaborate with Provider Network, Product, Analysts, IT, and cross-functional teams to align strategies and quality improvement priorities in contracting, vendor relationships, sales, product development, and procurement. Manage a team of associates to achieve optimized quality and star ratings from stakeholders and network providers.

Responsibilities

1. Support quality improvement processes across all regions where we have members.
2. Collaborate cross-functionally and with vendors to define projects that support corporate initiatives with measurable, timely results.
3. Analyze quality-related data to design, develop, monitor, and evaluate clinical and administrative service studies for quality improvement.
4. Prepare reports, abstracts, and presentations on process/outcome measures and present findings to organizational committees and at professional conferences.
5. Manage the Provider Incentive Program (PIP) to improve quality performance, including HEDIS, CAHPS, and HOS measures.
6. Define and implement enterprise strategies for quality excellence, including measurement and refinement.
7. Manage engagement and education tools for providers and vendors, reporting on their effectiveness.
8. Develop measurement tools, metrics, and control tools to monitor and sustain project results.
9. Ensure corrective actions are implemented company-wide, applying statistical procedures for data analysis and evaluation.
10. Participate in quality improvement committees, review operational processes, and document new processes.
11. Support NCQA accreditation efforts and compliance with regulatory authorities, including HEDIS, QARR, and Star processes.

Qualifications

• Bachelor’s Degree in a health services field (Required); Advanced degree (Preferred)
• Six Sigma Green or Black Belt (Preferred)
• 5–8+ years’ experience in healthcare, preferably managed care (Required)
• Ability to work across multiple locations, requiring site visits (Required)
• Staff/process management experience (Preferred)
• Proficient in MS Access (Preferred)
• Experience with data analysis (Required)
• Knowledge of relational databases and statistical analysis (Preferred)
• Knowledge of QI methodologies - PDSA and DMAIC (Required)
• Familiarity with HEDIS, QARR, CAHPS, HOS (Required)
• Strong analytical skills for data presentation (Required)
• Ability to prioritize work to meet deadlines (Required)

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Management, Project Management, and Quality Assurance

Industries

• Insurance