Highmark Health Manager, Quality Improvement (Medicaid) in Pittsburgh, Pennsylvania



This job, with oversight from the Director, is responsible for leading the strategic planning, development, implementation and monitoring of the quality portion of the Quality Improvement/Utilization Management Program and Work Plan Initiate (within all Gateway Health Plan SM Departments) collaborative cross functional programs and initiatives based on sound data analysis to drive the development, implementation, monitoring and evaluation of quality related programs and services to meet business needs and external drivers and deliver on corporate goals and objectives. The incumbent ensures the standards of the National Committee for Quality Assurance (NCQA) and all other applicable State and Federal Regulatory/Accrediting Agencies are appropriately integrated into the Quality Improvement/Utilization Management Program. The incumbent is accountable for defining and leading the program management of the DPW’s MCO Pay for Performance Program, the Gateway Provider Pay for Performance Program and other assigned high impact Quality Improvement initiatives. Builds and executes the business plans (strategic and operational) for various complex and corporate programs and initiatives; gain approval from key stakeholders and customers (internal and external) and assure ongoing program and initiative implementation to support the achievement of corporate and departmental goals and objectives. Analyzes the effectiveness of the business plan and makes recommendations for program changes.Manages and develops QI staff and resources. Assigns staff to support cross-departmental project teams. Assures project teams are operating effectively and are completing work within required timeframes. Conducts performance reviews and ongoing staff development. Develops and manages department budget.


  • Strong ability to communicate effectively, both verbally and in writing with external regulators and internal staff and management at all levels, including senior leadership.

  • Provide day-to-day leadership and representation for the Quality Improvement Department/Quality Improvement Program both internally and externally.

  • Assist Director in the planning, design, development and implementation of the Quality Improvement Department Strategic Plan based upon the strategic initiatives and direction of the organization.

  • Monitor and report, on a regular basis, the status of the QI Department Strategic Plan initiatives and activities.

  • Present quality improvement program information within the Gateway organization, and externally to Gateway’s committees, regulatory bodies, professional organizations, business partners, delegates, and vendors

  • Provide leadership and direction for direct report staff and matrixed employees to ensure department activities are performed and strategic initiatives are accomplished.

  • Conduct performance reviews and ongoing staff development.

  • Coordinate the successful definition, development, implementation delivery and monitoring of the quality portion of the Quality Improvement/Utilization Managementand Work Plan.

  • Collaborate with all Departments to initiate cross-functional quality improvement related teams, activities, programs and services. Ensure Total Quality Management (TQM) concepts are utilized in the development, implementation, monitoring and evaluation of all quality activities, programs and services.

  • Ensure the standards of the National Committee for Quality Assurance (NCQA) and all applicable State and Federal Regulatory Agencies are appropriately integrated into the Quality Improvement/Utilization Management Program.

  • Assist in the preparation of the annual QI budget based upon the QI Strategic Plan, established quality improvement program activities and responsibilities, and the fiscal direction of the organization.

  • Assist in the planning and preparations for external audits and surveys, including but not limited to NCQA Accreditation Surveys, CMS, Department of Public welfare, Department of Health. Evaluate, recommend and implement processes and programs as necessary to maintain NCQA compliance.

  • Function as a consultant to evaluate the Gateway organization, analyzing processes and systems to recommend solutions regarding NCQA vulnerabilities and gaps.

  • Assist in evaluating the NCQA standards against all applicable State and Federal Regulatory Agency standards and ensure that appropriate compliance has been determined utilizing the most stringent standards or according to fixed rules and regulations.

  • Oversee and lead the organization-wide HEDIS Business Process within Gateway Health Plan, which includes HEDIS, CAHPS and HOS.

  • Responsible for managing the Health Plan Employer Data and Information Set (HEDIS) Business Process within Gateway Health Plan to ensure appropriate vendor relationships are established, timeframes for required activities are met, successful completion of the annual HEDIS compliance audit and reportable HEDIS data submitted to NCQA and related agencies.

  • Collaborate within all Gateway Departments to analyze HEDIS performance to develop, implement and monitor interventions and activities to improve HEDIS and quality revenue management. Within the HEDIS Business Process, managing the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcomes Survey (HOS), including vendor selection, management, reporting, analysis and driving organization-wide change based on the results and opportunities identified.

  • Communicate and coordinate with all involved parties, the timeframes and activities managed under the scope of the HEDIS Business Process. Collaborate with other Gateway departments to establish appropriate vendor relationships, identify auditor relationships, and ensure contacts with appropriate state and federal regulatory agencies are established.

  • Have the final approval of the HEDIS Roadmap and ensure its timely submission.

  • Function as the primary contact for all communications and planning activities for the onsite HEDIS audit. Plan and coordinate onsite preparations for the HEDIS audit with all related departments. Ensure timely submission of all data to auditor, NCQA and associated state and federal regulatory agencies.

  • Annually, in collaboration with all involved departments, evaluate the HEDIS Business Process to identify systems issues, process inefficiencies, training or education gaps, and lapses in communication. Perform barrier analysis and identify opportunities for improvement.

  • Collaborate within all Gateway Departments to analyze HEDIS performance rates against Quality Compass benchmarks.

  • Develop, implement and monitor interventions and activities to improve HEDIS and Pay for Performance (P4P) measures outcomes.

  • Lead and manage the on-site Quality Improvement activities for Gateway.

  • Conducton-site visits and medical record reviews via nurse reviewers to assess the care provided in the practice setting in compliance with Gateway and external requirements

  • Aggregate data to identify network wide opportunities for improvement and the development of action plans to address the findings

  • Conduct site visits and medical record reviews for high volume specialists and facilities in accordance with Gateway and external requirements

  • Collect and analyze data for EPSDT and encounter reporting to other Gateway departments for compliance

  • Direct the deployment of the nurses during the HEDIS timeframe for the hybrid Medical record data abstraction phase of the HEDIS survey and oversee the data entry, quality check ,inter-rater reviews and all follow up components of the process

  • Ensure the timely and effective identification of potential quality of care issues.

  • Conductassessments via nurse reviewers of quality of care concerns that are brought to the attention of the QI Department for future investigation, including the collection and review of medical records, collaboration with medical directors, and assessments of available information.

  • Trackand trenddata sets, including but not limited to mortalities, never events, serious adverse events, etc. to proactively identify emerging trends and issues.

  • Lead the health care disparity efforts of the Gateway organization through collaboration and partnering to address issues with: health care disparities that can drive improvements in HEDIS rates;employee education and awareness efforts for improved levels of member satisfaction; provider awareness and education of the role of health care disparities and literacy in overall health and outcome.

  • Lead the multi-disciplinary Health Care Disparities Committee to drive change across the organization.

  • Other duties as assigned or requested.



  • Bachelor’s Degree in clinical or human services OR High School Diploma with 6 yearsof experience

  • 4years of experience in Quality Improvement/Management

  • 2years of previous supervisory or team lead experience


  • For Nurse Applicants, a Pennsylvania RN License or Eligible for Pennsylvania RN Licensure by Endorsement

  • 4years of combined experience in Quality Improvement, Utilization Management, Disease Management, Preventive Health or Case Management in a managed care health plan environment

  • 4years of leadership experience in NCQA survey preparation

  • 4years of managed care health plan experience in Medicaid / Medicare

  • Understanding of health care diseases or conditions, their management, health care delivery systems and processes

  • Certification in Quality Management Principles/Project Management and /or Lean Six Sigma


  • None


Does this role supervise/manage other employees?



Is Travel Required?


Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies


Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity