Quality Rating System (QRS) Program Manager - Internal This opportunity is internal and available to current HCA employees only. This is a new position addressing a federal requirement to produce and maintain a single web page of information to help Apple Health clients select a managed care plan. This position will regularly facilitate meetings with the owners of MCO information to pull together this project. If you are a highly organized proactive person with familiarity with Apple Health care options, this may be the opportunity for you! The mission of the Medicaid Programs Division (MPD) in the Health Care Authority (HCA) is to provide high-quality health care through innovative health policies and purchasing strategies which assist in the purchase and delivery of health care services to qualified Washington citizens. MPD staff work across the agency, between agencies, and in partnership with health care providers and community stakeholders to develop and manage high-quality, evidence-based health care programs and purchasing services that enhance clients' ability to access appropriate, quality health care. The purpose of this program manager is to provide statewide program management and oversight of the Medicaid and CHIP managed care Quality Rating System (QRS) requirements and management of the external quality review organization (EQRO) contract. This will include collecting, organizing, and analyzing data related to managed care programs; developing timetables and work plans; and managing the contract budget. The position examines compliance with federally and contractually required reporting and monitoring activities. This position will also interact with Managed Care Organizations (MCOs) to discuss quality outcomes and problem-solving solutions to meet our customer needs. This position is eligible to telework and is typically not required to report on-site. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. All agency employees are required to report on-site in Olympia on their first and last days of employment to pick up and return state-issued equipment, regardless of telework status or location. Some of what you will do: Provide expert level analysis to management, staff, and both internal and external customers regarding client enrollment options, public-facing information, Apple Health MCO quality deliverables, and delivery system design. Guide resolution for complex issues affecting the statewide program and information available for client enrollment options. Evaluate QRS results and identify areas where policies, processes, or requirements need to change. Establish expectations for work involving cross-functional teams, resolve issues affecting quality outcomes, and ensure resulting products and information meet requirements. Attend meetings with agency staff and external contractors to understand and impact program and systems design. Review MCO-related expectations, including contract language, provider billing guides, RCW and Washington Administrative Code (WAC).Perform EQRO quality review and provider survey activities within Apple Health managed care quality. Evaluates contractor findings and MCO performance. Serve as the agency's lead to ensure statewide program compliance. Lead the quality-related program direction to support continuous improvement in MCO networks.
Required qualifications:
Statewide Health Care Program Management: Demonstrated ability to develop, implement, administer, and evaluate complex statewide health care programs, establishing program goals, priorities, work plans, performance expectations, and operational strategies that support agency objectives. Strategic Planning and Program Development: Demonstrated ability to translate organizational priorities, legislative direction, health care policy, and emerging program needs into short- and long-term strategies, program objectives, implementation plans, and measurable outcomes. Policy, Legislative, and Regulatory Leadership: Demonstrated ability to analyze complex state and federal health care requirements, proposed legislation, administrative rules, and policy changes and provide authoritative recommendations regarding program impacts, implementation strategies, risks, and administrative feasibility. Fiscal and Resource Management: Demonstrated ability to manage program budgets, expenditures, contracts, staffing or other resources; establish priorities; evaluate competing demands; and allocate resources to achieve program objectives while maintaining fiscal and operational accountability. Program Performance and Continuous Improvement: Demonstrated ability to establish performance expectations and evaluate program quality, effectiveness, outcomes, risks, and operational performance using qualitative and quantitative information to drive continuous program improvement. Leadership and Stakeholder Management: Demonstrated ability to lead multidisciplinary teams, professional staff, project teams, contractors, providers, and internal and external partners while establishing accountability, resolving competing priorities, and building collaboration around statewide program objectives. Required competencies: Equity lens – All HCA employees are required to consider equity in their decisions, processes, and day-to-day work, including how their work may affect the people and communities we serve. The ability to take action to learn and grow – You take action to learn and grow by seeking new perspectives, learning from experiences, and using what you've learned to continuously improve how you work and serve others. The ability to take action to meet the needs of others – You take action to meet the needs of others by listening, understanding different perspectives, and responding with care, respect, and solutions that support the people of the communities we serve.
Preferred qualifications:
Education/experience: A master's degree with major study in public health, behavioral health, public administration, business administration, social work, or closely related field AND three (3) years consultative or supervisory experience in health services, social services, Medicaid, behavioral health, or other health care programs OR Nine (9) years of experience in the related fields above. Demonstrated ability to communicate, advocate, negotiate, listen, and build effective working relationships with a variety of individuals, stakeholders, and groups internal and external to the program. Demonstrated ability to communicate effectively through written, verbal, and presentation methods using Plain Talk principles. Demonstrated ability to effectively use computer applications and information systems, including Microsoft Excel, Microsoft Access, Microsoft Word, ACES and ProviderOne, Demonstrated ability to solve complex problems using independent judgment, identify critical issues, and develop recommendations for provider reviews, procedural changes, WAC or billing instructions, and system improvements that increase efficiency and support program goals. Demonstrated ability to analyze situations, identify policy needs, develop strategies and goals, establish priorities, and use data to support informed decision-making. Demonstrated ability to apply knowledge of ProviderOne claims data, Washington Apple Health programs, and applicable federal and state rules and regulations. Demonstrated ability to analyze, interpret, and present Medicaid claims data, supporting documentation, and research to inform decisions and recommendations. Demonstrated ability to apply client utilization, care coordination, and case management practices to assigned work. Demonstrated ability to research and critically review documentation to determine whether information is consistent with established guidelines and sufficient to support a referral. Demonstrated ability to apply continuous quality improvement principles to evaluate processes and identify opportunities for improvement. Demonstrated ability to develop, implement, monitor, and evaluate quality standards and identify changes needed to achieve expected outcomes. Demonstrated ability to apply knowledge of state contracting requirements and contract compliance regulations when reviewing and evaluating contract activities. To apply for this position, you will need to complete your profile which includes three professional references and attach in separate files: A cover letter that specifically addresses how you meet the qualifications for this position Current resume To take advantage of veteran preference, please do the following: Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter. Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in careers.wa.gov.
