Mltc Quality Analyst

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

This role will support the strategic goals of the MLTC department so that all members are appropriately care managed, engaged in care, and receiving appropriate services using a holistic model. The role requires working knowledge of all Microsoft Office products.

• Analyzes and monitors contractual compliance and business operations to evaluate inefficiencies (e.g., member enrollment, eligibility verification, retention, PCSP development, monthly notes, authorizations, claims).
• Conducts oversight of fiscal intermediaries and auditing a random sample of member cases to determine contract compliance and audit records for any potential fraud, waste, and abuse.
• Supports the MLTC Clinical Quality Manager with analysis and sharing of Lenavi data to support continuous quality improvement with the goal of improving performance on the MLTC quality incentive.
• Supports the MLTC Clinical Quality Manager in provision of feedback to the New York Independent Assessor through the variance process which will involve the preparation of assessment variances.
• Supports the development and implementation of a comprehensive data reporting, evaluation, and monitoring plan for MLTC department with collaboration with MLTC leadership.
• Packages data from a variety of quality reports and data sources into a quality dashboard for the department.
• Measures and tracks key quality indicators and targets to effectively monitor quality outcomes for MLTC and MAP.
• Collates and summarizes reports based on audit finding with actionable next steps to ensure goals and departmental metrics are in compliance with DOH and Regulatory requirements.
• Partners with MLTC leadership for sharing of information and data-driven decision-making in alignment with strategic initiatives.
• Analyzes monthly claims data and conducts timely reconciliation in collaboration with UM, Claims, and providers.
• Supports development and timely revision of training materials based on feedback and changing regulations and workflows.
• Assists with monitoring of MLTC quality incentive methodology and participate in developing policies and procedures in conjunction with MLTC Clinical Quality Manager.
• Works with MLTC department leadership as needed to ensure accuracy of quality/compliance data and conducts validation as appropriate.
• Performs statistical analyses to support monitoring and evaluation of MLTC department as directed by MLTC Clinical Quality Manager.
• Assists with the identification, collection, input, and assembly of documents as required for external and internal audits.
• Develops and prepares reports, business presentations, and other materials as assigned.
• Assists with analyses and reporting for special projects as assigned.
• Attends approved in-service and external education and training as per department directives. 

• Bachelor’s degree in Computer Science, Information System, Health Administration, Business Administration, or Information Technology required. Bachelor’s Degree preferred.
• A minimum of 5 years’ data analysis and report development experience is required.
• Must have advanced working knowledge of Microsoft Office application including Excel and Access.
• Experience and knowledge of Managed Care Organizations and Managed Care plan operations is preferred.

Professional Competencies

• Integrity and Trust
• Functional/Technical skills
• Highly organized, detail oriented, dependable, and professional individual
• Ability to work independently and prioritize initiatives to meet report deadlines and thrive in a busy and dynamic work environment is a must.
• Written/Oral Communication: Ability to prepare written and oral reports and make effective presentations.
• Customer Focus: Ability to exercise tact and diplomacy and demonstrate strong customer service skills.
• Ability to make decisions related to area of functional responsibility and recognize issues requiring escalation.
• Ability to identify issues, conduct research, analyze, and interpret data, reach logical and sound conclusions, and make recommendations for action.
• Displays strong communication, interpersonal, and organizational skills across all levels coupled with effective problem solving, conceptual thinking, quantitative, and analytical skills.
• Self-motivated with ability to quickly learn about and adapt to changes in technology and regulatory requirements.