Job Description

JOB SUMMARY

1. Reports directly to: Director, External Quality Review
2. Direct reports to this position include:
   • Quality Reviewers
   • Senior Quality Reviewers
   • Project Coordinators
3. Other individuals or MetaStar staff with whom the person works on a regular basis:
   • State of Wisconsin Department of Health Services (DHS), Long Term Care/Waiver Programs and Medicaid Program Staff
   • Managed Care Organization (MCO) Compliance Officers, Quality Directors, MCO providers and other designated staff
   • Organizations operating Home and Community Based Services
   • Medicaid and Review Services Project Managers (PMs)
   • MetaStar Departments including IT and Finance

4. Essential duties and responsibilities:
   To successfully perform this job, the individual must be able to perform each essential job function satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

   • Serves as a primary contact for DHS and collaborators to develop and implement required and optional external quality review activities, as requested by DHS and in collaboration with DHS and MCOs and/or other program providers, i.e. county agencies.
   • External quality review is the analysis and evaluation of aggregated information on quality, timeliness, and access to services furnished by these programs.
   • Collaborates and communicates with VP, Director, PM and other team members to develop work plans and assign duties/tasks/responsibilities.
   • In cooperation with other internal managers, facilitates and coordinates review activities to ensure contract deliverables meet timeliness, quality and budget expectations.
   • In partnership with other internal managers, sets and revises priorities to maximize and leverage staff to create efficiencies and respond to DHS directives.
   • Participates/conducts mandatory and optional review activities as a quality reviewer/consultant for Medicaid managed care, as needed.
   • Leads inter-rater reliability testing in order to achieve standards of accuracy and consistency in applying review guidelines for specific review activities.
   • Promotes positive internal/external client relations.
   • Leads, participates and supports efforts to improve existing processes and develops new processes/standard operating procedures (SOPs) including identification of issues/barriers and methods for improvement. Promotes flexibility in process design, implementing PDSA cycles as needed.
   • Coaches assigned staff, provides technical advice, and facilitates connections with other subject matter experts.
   • May serve as a subject matter expert regarding external quality review (EQR) mandatory and optional review activities described in the managed contracts according to Federal and State requirements.
   • Reviews written work products prepared by others.
   • Communicates routinely and proactively regarding project progress, issues and needs, etc.
   • In cooperation with other managers, develops contingency plans in response to staffing changes.
   • Develops and delivers presentations to internal and external groups, as needed.
   • Actively leads team Internal Quality Control (IQC).
   • Verifies time reporting and approves timesheets for assigned staff.
   • All other duties as assigned

QUALIFICATIONS, REQUIREMENTS, ETC.
The requirements listed below are representative of the knowledge, skills, and/or abilities required to successfully perform this job at the minimum level. Additional requirements are listed as preferred.

• Bachelor’s degree in health-related or social services field. Master’s degree preferred.
• 5-8 years of supervisory or continuous team/project management or leadership experience.
• Minimum of five years of project management experience managing complex projects.
• Experience of continuous quality improvement, process improvement and Lean principles.
• Experience and knowledge of regulatory reviews and compliance-based surveys such as Federal managed care regulations, DHS health care regulations and licensing, health care organization accreditation standards.
• Managed care experience preferred, including knowledge of managed care delivery systems, organizations and financing.
• Knowledge of the conditions, current philosophies, nationally recognized approaches, and community alternatives for the adult and children’s populations being served under the DHS managed health and long-term care waiver programs.
• Effective analytical and communication (oral and written) skills.
• Knowledge of Medicaid policies, data systems and processes.
• Knowledge and proficiency in using electronic medical and health records systems
• Ability to work well independently and within a team structure.
• Self-motivated, adaptable critical thinker with a strong desire to learn and apply existing and new skills.
• Excellent communication (oral and written) and small and large group facilitation skills.
• Proficiency in Microsoft Office applications.
• Ability to work well independently and within a team structure.
• Valid Driver’s License or ability and means to travel as required
• Interest and availability for in-state and overnight travel (5%)

ORGANIZATIONAL CORE COMPETENCIES:

• Exemplifies MetaStar’s Mission, Vision, Values
• Uses Quality Improvement Concepts in Daily Practice
• Provides Excellent Customer Service
• Shows Initiative
• Applies MetaStar’s Leadership System

PHYSICAL EFFORT AND WORKING CONDITIONS

The requirements and conditions described below are representative of the general environment the individual is exposed to on a day-to-day basis while performing this job.

• Manual Dexterity: Ability to operate computer and telephone
• Physical Effort: Ability to sit or stand for five-to-eight hours per day (depending on scheduled FTE); occasionally lifting up to 15 pounds.
• Equipment Used: Computer and telephone
• Working Conditions: Traditional office environment; required to work on a computer five-to-eight hours per day (depending on scheduled FTE)

QUALIFICATIONS, REQUIREMENTS, ETC.
The requirements listed below are representative of the knowledge, skills, and/or abilities required to successfully perform this job at the minimum level. Additional requirements are listed as preferred.

• Bachelor’s degree in health-related or social services field. Master’s degree preferred.
• 5-8 years of supervisory or continuous team/project management or leadership experience.
• Minimum of five years of project management experience managing complex projects.
• Experience of continuous quality improvement, process improvement and Lean principles.
• Experience and knowledge of regulatory reviews and compliance-based surveys such as Federal managed care regulations, DHS health care regulations and licensing, health care organization accreditation standards.
• Managed care experience preferred, including knowledge of managed care delivery systems, organizations and financing.
• Knowledge of the conditions, current philosophies, nationally recognized approaches, and community alternatives for the adult and children’s populations being served under the DHS managed health and long-term care waiver programs.
• Effective analytical and communication (oral and written) skills.
• Knowledge of Medicaid policies, data systems and processes.
• Knowledge and proficiency in using electronic medical and health records systems
• Ability to work well independently and within a team structure.
• Self-motivated, adaptable critical thinker with a strong desire to learn and apply existing and new skills.
• Excellent communication (oral and written) and small and large group facilitation skills.
• Proficiency in Microsoft Office applications.
• Ability to work well independently and within a team structure.
• Valid Driver’s License or ability and means to travel as required
• Interest and availability for in-state and overnight travel (5%)

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