Clinical Affairs January 1, 2013 through December 31, 2013 A brief description of Network Health s quality management improvement program, including a written description of the QI program structure; the program s pharmacy, medical and behavioral health care aspects; patient safety improvement; multicultural health care; QI function oversight; a description of QI activity devoted resources; QI committee role, structure, and function; and the annual work plan Quality Management and Improvement Program Description 1
Table of Contents Executive Summary... 3 Mission Statement... 4 Vision Statement... 4 Core Values... 4 I. Purpose... 5 II. QI Program Accountability: Authority and Responsibility... 5 III. Scope... 5 IV. Program Objectives... 5 V. Organizational Structure... 6 A. Program Staff... 6 B. Program Staff Physician/Psychologist... 7 C. Program Staff Non-physician... 10 D. Program Oversight... 23 VI. Quality Management and Improvement Methods and Measures... 33 VII. Utilization Management... 34 VIII. Population Health and Wellness... 35 IX. Care and Disease Management Programs... 35 X. Behavioral Health Services Measures and Activities... 36 XI. Patient Safety Measures and Activities... 36 XII. Multicultural Health Care... 37 XIII. Delegation... 39 XV. Annual Work Plan and Program Evaluation... 39 Attachment 1... 42 Attachment 2... 43 Attachment 3... 44 Attachment 4... 45 Attachment 5... 46 2
Executive Summary This document describes the scope, structure, and function of Network Health s quality management and improvement program (QMIP). It confirms the ultimate authority and responsibility of the Tufts Health Plan (THP) board of directors for the quality of care and services delivered to Network Health LLC s enrollees. The QMIP also defines the lines of accountability between the quality improvement program and the board of directors. The objective of the QMIP is to foster initiatives that support continuous improvement and innovation in how Network Health meets its enrollees health care needs and makes sure that enrollees get high-quality health care in the right place, at the right time, and in the most effective and efficient manner possible. The QMIP provides a detailed description of the organizational structure, including staffing and committees, required to support Network Health s quality initiatives. This document provides an overview of quality management and improvement methods and measures, followed by a high-level overview of care and disease management programs. The document also includes information about how Network Health monitors and improves behavioral health services, and prioritizes its enrollees safety. Network Health also attaches the quality management and improvement work plan, which outlines major FY13 targets and milestones. The documents required to develop the QMIP consist of the utilization management (UM) program description, the care management program description, the various disease management program descriptions, and trend reports from various departments, including utilization management, disease management, and care management. The appropriate quality committees have separately vetted and approved these foundation documents. 3
Mission Statement To improve the health and wellness of the diverse communities we serve. Vision Statement Every life improved through access to high-quality, affordable health care. Core Values Our members come first Their health care needs guide all our decision-making. Our partners are key to our success We partner with members, health care professionals, and community groups to advance excellence in care and service. Our employees are our greatest asset We respect the worth of each employee. Our work environment promotes creativity, teamwork, professional growth and development, and a bias to action. Our integrity is absolute We are good stewards of our resources while being socially responsive to the needs of the diverse communities we serve. Our services are driven by quality We strive for continuous improvement and innovation in all that we do. 4
I. Purpose This document describes the scope, structure, and function of Network Health s quality management and improvement program (QMIP). The purpose of the QMIP is to provide the operational structure and processes necessary to achieve the goals and objectives set by the THP board of directors for the quality of care and services for Network Health LLC s enrollees. Network Health designed its QMIP to provide, manage, and document ongoing activities that evaluate and improve the quality of care and services delivered to Network Health enrollees. II. QI Program Accountability: Authority and Responsibility The THP board of directors, which is Network Health LLC s governing body, has ultimate responsibility for the quality of care and service delivered to Network Health enrollees, and retains overall responsibility for the QMIP (see Attachment 2). THP s board of directors reviews and approves the QMIP description annually, first through its care management subcommittee, and designates the plan-level quality management committee (QMC) as the body responsible for overseeing quality management and improvement (see Attachment 4). Network Health describes the functions of the QMC and its subcommittee, the quality improvement committee (QIC) (see Attachment 5), later in this document. III. Scope The scope of the QMIP encompasses the assessment, monitoring, and improvement of all aspects of care and service enrollees receive, including: Inpatient and outpatient care at all acuity levels Primary and specialty care, including care that behavioral health providers, ancillary providers, and other contracted providers deliver Services that Network Health and its contractors deliver IV. Program Objectives Network Health strives for continuous improvement and innovation in meeting enrollees health care needs. The plan strives to ensure that enrollees obtain high-quality health care in the right place, at the right time, and in the most-effective and efficient manner possible. Network Health s overarching objective is to be the highest value managed care organization serving Massachusetts residents with low and moderate incomes. The plan reflects its commitment to improving its enrollees health and well-being in the QMIP objectives listed below: 5
Identify and act upon improvement opportunities using HEDIS data and the quality improvement goals of the MassHealth MCO program and Commonwealth Care Oversee receipt and analysis of provider and enrollee satisfaction data and implement improvement activities in response to analyzed survey results Oversee implementation of utilization and care management processes, including reviewing data related to utilization management/care management (UM/CM) service satisfaction and improvement activities Ensure the development of processes and structures to ensure and track continuity of care between medical and behavioral health care providers Ensure the development of processes and structures to ensure and track continuity of care between medical care providers who deliver primary care and specialty care Oversee grievance and appeal processes in the organization to increase timeliness and responsiveness and identify opportunities for service improvement Ensure that Network Health s clinical practice guidelines are consistent with national, state, and local quality and UM criteria Support efforts to improve patient care and service and to monitor the effectiveness of implemented changes Improve aggregation and analysis of data to develop more meaningful opportunities for reporting, education, and improvement, including expanded reporting on provider and enrollee race, ethnicity, language (REL), and their relationship to potential disparities in health care and health outcomes Develop initiatives to address disparities in health care and health outcomes related to REL data and encourage culturally appropriate care and service for enrollees Monitor clinical and nonclinical service access and availability and implement corrective action where necessary Ensure the quality of care available to enrollees by overseeing provider credentialing processes, evaluating providers medical record and treatment records, and working with providers to improve quality of service Disseminate quality activity findings and provide information and support in order to stimulate the improvement process within Network Health and contracted clinical and ancillary providers Lead Network Health s efforts to maintain an excellent NCQA-accreditation rating and continue to improve the plan s accreditation score Network Health includes program activities and performance goals in the annual QMI work plan. A summary of the FY13 work plan appears as Attachment 1. V. Organizational Structure A. Program Staff Network Health s QMIP draws on company-wide expertise and resources. The following is a brief description of the individuals and responsible business areas that support the program. These individuals and responsible business areas include, but are not limited to, a dedicated quality department (QD) and its staff and responsibilities. Network Health includes an 6
organizational chart of the QMIP as Attachment 2 and an organizational chart of the QD as Attachment 3. B. Program Staff Physician/Psychologist 1. Vice President/Chief Medical Officer (VP/CMO): The chief medical officer has overall responsibility for all clinical, pharmacy, and quality programs and initiatives. The chief medical officer reports to the president and is a member of Network Health s executive senior leadership team. The chief medical officer chairs the physician advisory committee and is a member of the UM committee, the technology review committee, the global benefits committee, the pharmacy & therapeutics committee, the quality management committee, the quality improvement committee, the clinical quality steering committee, and other quality and clinical steering committees. The chief medical officer supervises the vice president of clinical affairs, senior medical directors, the medical director for medical utilization management, the medical director for behavioral health, the associate medical director for pharmacy, the senior director of pharmacy and the manager, program evaluation team. Additionally, the chief medical officer provides clinical oversight for the following: Benefit exception reviews Clinical / adverse action appeals Clinical grievances Provider and facility credentialing 2. Medical Director for Medical Utilization Management: The medical director for medical utilization management (UM) is actively involved in the development of Network Health Clinical Guidelines, annual review of Utilization management clinical screening criteria, and evaluation of certain program outcomes. The medical director for medical utilization management reports to the chief medical officer and chairs the utilization management committee and the new technology committee, co-chairs the quality improvement committee and the clinical quality steering committee, and is a member of the global benefits committee, the physician advisory council and other clinical and quality committees. The medical director for medical utilization management serves as the primary physician advisor for UM programs as well as serves as one of the medical advisors for the medical management clinical team. The medical director for medical utilization management conducts primary medical evidence reviews and makes decisions of medical necessity in cases of prior authorizations, concurrent reviews, and/or retrospective reviews that do not meet Network Health criteria for medical necessity/clinical appropriateness or quality. The medical director for medical utilization management is responsible for coordinating the Network Health Physician Team to respond to the following: Performance of medical case reviews for medical necessity Performance of medical reviews for benefit exceptions 7
Performance of appeal reviews based on medical necessity or adverse determinations Investigation of and response to clinically-based member grievances The medical director for medical utilization management supervises the associate medical director for medical utilization management and coordinates the activities of physician reviewers.. 3. Senior Medical Director for Credentialing and Enrollee-generated Clinical Provider Grievances: The senior medical director for credentialing and enrollee-generated clinical provider grievances is responsible for overseeing the credentialing process and providing back-up support to the senior medical director for utilization management, appeals, grievances and program evaluation as needed. The senior medical director reports to the chief medical officer, chairs the credentialing committee and is a member of the utilization management committee (UMC), the physician s advisory council (PAC) and the new technology committee. 4. Associate Medical Director for Medical Utilization Management: The associate medical director serves as physician advisor for the medical management team of nurses. The associate medical director conducts primary physician evidencebased reviews and makes decisions of medical necessity in cases of prior authorizations and/or concurrent reviews that do not meet Network Health criteria for medical necessity/clinical appropriateness or quality. This position reports to the senior medical director for UM, appeals, grievances, and program evaluation and is a member of the utilization management committee, the new technology committee and other clinical and quality committees. The associate medical director for medical utilization management serves as clinical subject matter expert and physician advisor to the clinical quality subcommittee for maternal and child health and assists the Network Health physician team in communications and relationships with participating physicians and providers. The associate medical director for medical utilization management reports to the medical director for medical utilization management. 5. Associate Medical Director for Pharmacy: The associate medical director for pharmacy serves as the lead physician advisor for Network Health s pharmacy staff, ensuring clinically appropriate, cost-effective management of pharmacy benefits. This role is integral in the establishment of medication request guidelines. The associate medical director for pharmacy assists the Network Health physician team in communications and relationships with participating physicians and providers. The associate medical director for pharmacy reports to the 8
chief medical officer, chairs the pharmacy and therapeutics (P & T) committee, co-chairs the new technology committee and serves on the pharmacy planning committee. 6. Medical Director for Behavioral Health: The medical director for behavioral health is a psychiatrist who conducts primary behavioral health evidence-based reviews of requests for behavioral health services and/or levels of care which do not meet Network Health criteria/guidelines for behavioral health necessity/clinical appropriateness or quality. The medical director for behavioral health serves as liaison to the behavioral health practitioner and provider communities and provides guidance and expertise to the clinical staff in the area of behavioral health. This position reports to the chief medical officer, is a member of the UMC, a consultant to the P & T committee, a member of the quality improvement committee, the physician advisory council, the behavioral health physician advisory council, and the behavioral health quality improvement subcommittee. The medical director for behavioral health supervises the associate medical director(s) for behavioral health. 7. Associate Medical Director for Behavioral Health: The associate medical director for behavioral health is a psychiatrist and serves as a physician advisor for the behavioral health department, reviewing cases with providers when there are identified clinical issues or questions about an enrollee s care. The associate medical director for behavioral health regularly reviews cases and provides support to behavioral health care managers. This position reports to the medical director for behavioral health. 8. Physician Reviewers: Network Health employs/contracts with board certified medical and behavioral health physicians who review UM cases (including appeals) and licensed clinical psychologists who assist in the review of psychological services and testing wherever either expertise or available resources do not exist within the company. The physician advisors approve and deny care according to Network Health s UM criteria, clinical guidelines, and policies and procedures. A Network Health medical director is available for consultation 24 hours a day, seven days a week to address questions of care for enrollees and urgent medical necessity determinations. In addition, a medical director is available to discuss a case with a primary care practitioner, a hospital attending physician, or a specialty provider at any time. Physicians at Network Health may perform one or more of the following activities as appropriate by medical or behavioral health practice requirements: Reviews cases for medical necessity Reviews cases for benefit exceptions Reviews cases for appeals Investigates and responds to clinically-based enrollee grievances Attends clinical rounds for all care teams Investigate potential quality of care concerns. 9
C. Program Staff Non-physician 1. Vice President of Clinical Affairs: The vice president of clinical affairs is responsible for providing oversight for all of Network Health s UM, care management (CM), transitions of care, clinical community outreach, disease management, prevention and wellness, and quality operational activities, program initiatives, and medical expense goals. Further, the vice president of clinical affairs is responsible for ensuring compliance with all regulatory and accreditation standards. This Vice President is responsible for HEDIS activities, NCQA readiness, EQRO and State Quality Improvement Projects (QIP), process workflows, documentation including policies and procedures, and implementation and evaluation of all UM program requirements. The vice president of clinical affairs is responsible for the successful implementation and operationalizing of any new programs such as the model of care for the dually-eligible beneficiary ages 21 through 64 demonstration project. The vice president of clinical affairs reports to the chief medical officer and is a member of Network Health s executive senior leadership team. The vice president of clinical affairs is a member of the UM committee, the quality management committee, the quality improvement committee, the clinical quality steering committee, the quality concerns committee, the global benefits committee, the new technology committee, the behavioral health physician advisory council, and other quality and clinical steering committees. The vice president supervises the director of behavioral health, the director of medical management, the director of integrated care management, the director of quality, the manager of intake and outreach coordination, and the clinical affairs education and training department 2. Director of Medical Management: The director of medical management is responsible for medical utilization management functions including prior authorization, concurrent review, referral management, and utilization management transitions of care. Network Health s focused medical transitions of care program is a 12-week program that provides intensive care coordination for those enrollees identified with increased risk for readmissions and emergency room utilization following discharge from an inpatient admission. This director is responsible for oversight of the medical denials management process. The director of medical management directs processes and implements changes to ensure high-quality, costeffective services to enrollees. The director of medical management works with the director of behavioral health, the director of integrated care management, and the medical directors to achieve Network Health s medical management goals including improved enrollee outcomes, appropriate utilization of healthcare services, and quality of care. The director of medical management collaborates and coordinates efforts with other clinical affairs departments as well as with other internal departments including claims, provider relations, provider 10
contracting, customer service, finance, and information technology (IT) in support of medical management initiatives and operations. The director of medical management supervises the manager of medical utilization management. The director of medical management reports to the vice president of clinical affairs. 3. Director of Behavioral Health: The director of behavioral health is responsible for behavioral health utilization management functions including prior authorization, concurrent review, referral management, and utilization management transitions of care. Network Health s focused behavioral health transitions of care program is a 12-week program that provides intensive care coordination for those enrollees identified with increased risk for readmissions and emergency room utilization following discharge from an inpatient admission. This director is responsible for oversight of the behavioral health denials management process. The director of behavioral health directs processes and implements changes to ensure high-quality, cost-effective services to enrollees. The director of behavioral health works with the director of medical management, the director of integrated care management, and the medical directors to achieve Network Health s behavioral health management goals including improved enrollee outcomes, appropriate utilization of healthcare services and quality of care. The director of behavioral health collaborates and coordinates efforts with other clinical affairs departments as well as with other internal departments including claims, provider relations, provider contracting, customer service, finance, and IT in support of behavioral health initiatives and operations. The director of behavioral health supervises the manager of behavioral health and the behavioral health special projects manager. The director of behavioral health reports to the vice president of clinical affairs. The director of behavioral health and the director of medical management work collaboratively to ensure an integrated approach to providing utilization review, discharge planning, and transitions of care to support optimal outcomes for each enrollee. 4. Director of Integrated Care Management: The director of integrated care management/director of LTSS is responsible for Network Health s integrated care management program which offers a holistic, total-person, multidisciplinary approach to address enrollee needs employing medical, behavioral health, social case managers and clinical community outreach workers as a high-functioning integrated team. The director of integrated care management works with the directors of medical management and behavioral health and the medical directors to achieve Network Health s integrated care management goals including improved enrollee outcomes, appropriate utilization of healthcare services and quality of care. Based on the enrollees most critical needs, the medical, behavioral health, or social case manager is designated as the lead to work with the enrollee. However, the integrated approach allows the team to co-manage or tri-manage the members needs. Additionally, 11
it allows the team to partner with members, their providers, and their family/care givers throughout the continuum of care. Supporting the efforts of the integrated care team, the clinical community outreach team, reaches out to and engages Network Health s most vulnerable at-risk population (top 10 15 percent at-risk). The director of integrated care management/director of LTSS is responsible for the implementation and the day-to-day operations for the model of care of the dually-eligible beneficiary ages 21 through 64 demonstration project. Further, this director has primary accountability for all community-based long-term service and supports activities in support of the needs for this demonstration project population. In addition, the director of integrated care management/director of LTSS is responsible for the substance management program and the substance management transitions of care program. The substance management program is centered on assisting members in dealing with substance use. The director of integrated care management/director of LTSS supervises the manager of medical case management, the manager of behavioral health intensive clinical management (ICM) and social care management, the manager of clinical community outreach, the manager clinical manager, integrated care: Medicare and Medicaid Dually- Eligible Beneficiary Team, the manager of long-term services and supports, and the medical management special projects manager. The director of integrated care management/director of LTSS reports to the vice president of clinical affairs. 5. Director of Quality: The director of quality, a quality professional with a background in Six Sigma, is responsible all of Network Health s quality management and improvement activities and initiatives. These include: quality of care concerns, compliance with federal, state, and NCQA compliance; state and federal quality improvement initiatives; external quality review evaluation, HEDIS, CAHPS satisfaction surveys, and is active participant in MassHealth and Commonwealth care quality improvement meetings and initiatives. The director of quality chairs the clinical quality steering committee (CQSC), co-chairs the quality concerns committee and the quality improvement committee (QIC), and is a member of the quality management committee (QMC), the utilization management committee (UMC), the appeals committee, and other clinical and quality committees. The director of quality supervises the manager of quality-hedis, the manager of NCQA and compliance programs, and the quality managers. 6. Manager Intake and Outreach Coordination: The manager of intake and outreach Coordination is an experienced call center and customer service professional with a background of working in the healthcare environment. The manager ensures that the appropriate policies and procedures are in 12
place and followed by staff and assists in the development and maintenance of policies and procedures for the assigned area. Within the scope of intake and outreach coordination, the manager is responsible for all intake and outreach activities and initiatives. These activities include: initial authorization requests via phone and fax; verification of member demographic information; coordination of provider visits; wellness and prevention outreach campaigns; follow-up contact for emergency department (ED) utilization with appointment coordination; management and coordination of pre- and post-partum services for members with non-complex obstetrical diagnoses; follow-up appointment coordination for all inpatient behavioral health admissions: and outreach engagement calls for the clinical community outreach team. The manager supervises the supervisors of intake operations (2) and the supervisor of outreach. The manager reports to the vice president of clinical affairs. 7. Manager of Medical Utilization/Referral Management: The manager of medical utilization/referral management is a registered Nurse who is responsible for pre-certification, concurrent review, and retrospective review activities of the department. The manager ensures that the appropriate policies and procedures are in place and followed by staff and assists in the development and maintenance of policies and procedures for the assigned area. The manager supervises the supervisor, medical management operations, and staff responsible for department operations and reports to the director of medical management. 8. Manager of Behavioral Health Utilization/Referral Management: The manager of behavioral health utilization/referral management is a Licensed clinical who is responsible for pre-certification, concurrent review and retrospective review activities of the department. The manager ensures that the appropriate policies and procedures are in place and followed by staff and assists in the development and maintenance of policies and procedures for the assigned area. The manager supervises the supervisor, behavioral health, the senior behavioral health Clinician, and staff responsible for department operations and reports to the director of behavioral health. 9. Manager of Medical Care Management: The manager of medical care management is a registered Nurse who is responsible for all medical care management activities for members. The manager ensures that the appropriate policies and procedures are in place and followed by staff and assists in the development and maintenance of policies and procedures for the assigned area. The manager supervises staff responsible for department operations and reports to the director of integrated care management/director of LTSS. 10. Manager of Behavioral Health Intensive Care Management/Social Care Management: The manager of behavioral health intensive clinical management is a Licensed Clinician who is responsible for all behavioral health intensive clinical management activities for members. The manager ensures that the appropriate policies and procedures are in place 13
and followed by staff and assists in the development and maintenance of policies and procedures for the assigned area. The manager supervises staff responsible for department operations and reports to the director of integrated care management/director of LTSS. 11. Manager of Clinical Community Outreach: The manager is a licensed clinician who is responsible for all clinical community outreach and social care management activities. The clinical community outreach team works in the field and reaches out to and engages Network Health s most vulnerable atrisk population (top 10 to 15 percent at-risk). The social care management team works in the field to work with members whose needs are predominantly social and place members at risk for increased medical and behavioral health complications. The manager ensures that the appropriate policies and procedures are in place and followed by staff and assists in the development and maintenance of policies and procedures for the assigned area. The manager supervises staff responsible for department operations and reports to the director of integrated care management/director of LTSS. 12. Clinical Manager, Integrated Care: Medicare and Medicaid Dually Eligible Beneficiary Team: The clinical manager, integrated care: Medicare and Medicaid Dually-Eligible Beneficiary Team, assists in the design, implementation, oversight, audit activities, and operations of medical, behavioral health (BH), social case management, care coordination, and community outreach programs. The clinical manager is responsible for data management and regulatory reporting. The clinical manager, utilizing data, as defined by the Centers for Medicare & Medicaid (CMS), will work collaboratively with the other departments within clinical affairs, contracted partnership entities, and other departments within Network Health to ensure that departmental and organizational goals and objectives are met. Such goals include but are not limited to supporting CMS requirements, state initiatives as assigned, improvement initiatives for HEDIS measures, and compliance with NCQA standards. The clinical manager is responsible for the overall operations of the care management program which includes case management, care coordination, disease management, and clinical outreach activities associated with meeting the standards set for these programs in conjunction with regulatory (federal and state), contractual and/or accrediting requirements as well as appropriate documentation by the Interdisciplinary care Team (ICT). The manager supervises the supervisor of medical care management, the supervisor of BH intensive clinical management and social care management, and the care Navigators and reports to the director of integrated care management/director of LTSS. 14
13. Manager of Long Term Services and Supports (LTSS): The manager of Long-Term Services and Supports conducts program management activities and works to strengthen infrastructure for a long term community-based supportive services system that can better meet the needs and challenge of duallyeligible members wanting to live within their communities. This manager is responsible for the development and ongoing revision of program design and implementation to ensure compliance with regulations. The management is responsible for obtaining, maintaining, and analyzing community-based expenditure data; participating in budget activities; supporting the claims department to ensure that long term support services billing codes and rates are HIPAA compliant and set up accurately in Monument Express; and working with Executive Office of Health and Human Services (EOHHS) and Center of Medicare services (CMS) on developing policies to review and establish rates for specific services as well as communicating changes in policies, regulations and coding to providers. The manager of LTSS provides oversight, development, implementation and maintenance of the program according to the CMS, state requirements and/or initiatives, and Network Health goals. The manager of LTSS reports to the director of integrated care management/director of LTSS. 14. Special Project Managers: The special projects managers are responsible for clinical involvement for quality improvement activities, disease management activities, prevention and wellness activities, and oversight of specific clinical affairs vendor partners. The special projects managers work as both a partner to and liaison for the clinical operations managers and directors with the quality, analytics, and program evaluation departments. The special projects managers also collaborate with clinical department leaders to implement new initiatives, evaluate existing initiatives, and develop and prepare reports. The special project managers report to either the director of behavioral health or the director of integrated care management/director of LTSS. 15. Utilization Review Professional: The utilization review professional is an appropriately licensed clinician who conducts UM review activities. The utilization review professional coordinates and monitors care with participating practitioners, members, and provider organizations, using established criteria/guidelines for determining clinical necessity. The utilization review professionals collect and review clinical information for the pre-certification, concurrent review, and retrospective review processes. The clinicians approve requested service and care authorization requests according to member coverage benefit guidelines, UM criteria, state guidelines, and Network Health policies and procedures. 15
The utilization review professional may only deny authorization requests based on benefit design, benefit limitations, or contractual design. The clinicians have training and experience in the specific area of his/her utilization management functional areas. The utilization review professional is also responsible for utilization management transitions of care following specific acute inpatient medical or behavioral health admissions. The utilization review professionals report to either the manager of medical utilization/referral management or the supervisor of medical management operations or the manager of behavioral health utilization/referral management or the supervisor of behavioral health operations. 16. Care/Case Manager: The care manager/case manager (CM) is a licensed clinician who provides care/case management services. The CMs are responsible for assisting in the implementation of plans of care and the coordination of care management services for those members identified for care/case management services as those members in need of more intensive, long- term services than provided in episodic care management, transitions of care coordination, or health coaching. The care managers also approve requested care according to UM criteria, state guidelines, and Network Health UM policies and procedures. The care manager reports to the manager of medical case management or the manager of behavioral health intensive clinical management. A Network Health Nurse is available for consultation 24 hours a day, seven days a week to address questions of care for members, verify benefits, and perform medical necessity reviews. In addition, a Nurse is available to discuss a case with a primary care practitioner, a hospital attending physician, a hospital care/case manager, or a specialty provider or their representative at any time. 17. Clinical Community Outreach Staff: The clinical community outreach (CCO) Staff are social Workers, Licenses Practical Nurses, or Community Health Workers who are community-based and work with Network Health s most vulnerable population, those members at risk for poor outcomes. The clinical community outreach Workers engage members for up to 6 weeks to ensure that members understand the benefits available to them (plan and beyond plan) and how to access these benefits, to identify family and care-giver support, to connect with community resources, and to evaluate if ongoing care coaching or care/case management is required. 18. Intake Coordinator: The intake coordinator (IC) serves as the entry into Network Health s utilization review / referral process. The IC verifies member eligibility, confirms and updates demographic data, and begins the authorization process within Network Health s clinical information management application. The intake coordinator provides the initial request for clinical information and forwards the case to the appropriate clinical. Additionally, the intake 16
coordinator maintains proper documentation and responds to phone calls to assist members and/or providers with the utilization review process. The IC supports the medical and behavioral health Utilization Review and integrated care management teams to enhance and support Network Health s utilization management activities. The IC reports to a supervisor of intake and outreach Coordination. 19. Outreach Coordinator: The outreach coordinator (OC) performs various member outreach activities that support prevention and wellness initiatives, emergency department utilization follow-up coordination, pre- and post-natal coordination, appointment coordination, and clinical community outreach coordination. The outreach coordinator provides certain outreach components of the utilization management programs. The outreach coordinators outreach to members identified for specific Network Health programs and works with the clinical affairs teams to enhance and support these programs. The OC maintains proper documentation and facilitates coordination of services when indicated. The outreach coordinator reports to a supervisor of intake and outreach Coordination. 18. Manager, NCQA and Compliance Programs: The manager, NCQA and compliance programs reports to the director of quality. The manager is a member of the QIC and CQSC and is responsible for leading Network Health through preparedness for and implementation of NCQA, EQRO, and other accreditation and regulatory requirements. The manager also develops, implements, and modifies audit processes to ensure that the Plan is in compliance with all regulatory and accreditation requirements. The manager utilizes applicable organizational data and reporting to accomplish organizational quality-related NCQA and EQRO goals as well as supports Network Health s strategic quality goals and initiatives. Other key responsibilities include: Assisting in developing, implementing, and coordinating specific activities for each department within Network Health that has quality-related regulatory and/or accreditation requirements and coordinating the work of interdepartmental cross-functional teams that participate in the design of programs aimed at meeting accreditation requirements. 19. Quality managers: The quality managers report to the director of quality and the manager, NCQA and compliance programs, respectively. They are responsible for leadership and documentation of quality improvement activities; collection, analysis, and reporting of quality data and activity outcomes; and accreditation compliance activities. The quality managers also support the QIC and the QD s accountabilities, produce documents for state and accreditation reporting requirements, and provide quality control audit services for provider medical/treatment record review, denial of service communications and appeals notices. In addition, the quality managers support patient safety and quality of care analysis, reporting, and development of interventions to improve enrollees safety. 17
20. Manager, Quality-HEDIS: The manager, quality-hedis reports to the director of quality and is a member of the QIC and CQSC. The manager is responsible for implementation and coordination of HEDIS and CAHPS activities throughout the organization. In this capacity, the manager directs the quality control, execution, and reporting of HEDIS results, activities, and audits. The manager also provides coordination and leadership around efforts to improve HEDIS and CAHPS rates. 21. Medical Record Review Supervisor: Reports to the manager, quality HEDIS. The HEDIS medical record review supervisor is responsible for implementation and oversight of the medical record review for HEDIS hybrid measures. This includes ensuring that the scheduling, retrieval, and data abstraction processes meet or exceed NCQA, HEDIS, and other quality-related regulatory and accreditation requirements. In addition, the supervisor develops process measures and performance targets, at the program and individual staff level, that align with the Department s goals, tracks, and reports progress to the manager, HEDIS, works with the manager, quality - HEDIS and director, quality to make modifications or identify corrective actions, when required. 22. Medical Record Collection Supervisor: The medical record collection supervisor reports to the manager, quality HEDIS. The HEDIS medical record collection supervisor is responsible for implementation and oversight of the medical record collection process for HEDIS hybrid measures. This includes ensuring that the scheduling, retrieval, and storage processes for medical records meet or exceed audit requirements. In addition, the supervisor develops policies, process measures and performance targets at the program and individual staff level, that align with the Department s goals, tracks and reports progress to the manager, HEDIS, works with the manager, quality - HEDIS and director, quality to make modifications or identify corrective actions, when required. 23. HEDIS Nurse Reviewers: The HEDIS nurse reviewer has responsibility for ensuring the quality and timeliness of the medical record review process that supports the reporting of HEDIS hybrid measures for Network Health. The position is responsible for the execution of all aspects of the scheduling, retrieval, and abstraction processes associated with the review of medical records. This includes the training and supervision of a temporary staff of nurses from January to June dedicated to reviewing and abstracting medical records for scoring for HEDIS measures. The position works closely with the medical record review supervisor and the manager, quality - HEDIS in evaluation, issues identification, and issues resolution. This position will also participate in HEDIS improvement activities during the 18
year. 24. Quality Specialists: The quality specialists report to the manager, quality-hedis. They support quality improvement, accreditation, and HEDIS performance improvement and data-collection activities. In addition, the quality specialists provide ongoing quality control and evaluation of HEDIS and other data-collection methodologies. They also support the QD as needed. 25. Quality Coordinator: The quality coordinator reports to the manager, quality-hedis. Among other responsibilities, the quality coordinator supports the medical record review component of HEDIS, coordinates efforts to find data, such as chart location, and facilitates getting medical records to the HEDIS data-collection vendor, and coordinates quality control efforts of provider and enrollee HEDIS data-collection databases. The quality coordinator also supports the QD as needed. 24. Manager, Program Evaluation Team: Reports to the chief medical officer and is responsible for providing assistance with program design and evaluation including statistical significance testing of interventions necessary to meet state and other regulatory requirements. In addition, the manager, program evaluation team manages staff who produce reports and analyses to support regulatory and accreditation efforts. The manager, program evaluation team is also involved with data quality improvement initiatives and is a member of the QIC and the CQSC. 25. Vice President and Chief Technology Officer: The vice president and chief technology officer (CTO) reports to the president and is a member of the senior leadership team. The CTO is responsible for the overall operations of the information technology (IT) department and oversees implementation and maintenance for all aspects of company-wide applications, hardware infrastructure, hardware acquisition and integration, and strategic reporting and analysis. The CTO is a member of the QMC and the CQSC. 26. Director of E-Business and Business Intelligence: The director of e-business and business intelligence reports to the vice president and chief technology officer. The director of e-business and business intelligence is responsible for automating aspects of information exchange between the plan and members and providers including electronic claims submission and provider profiling. The director is also responsible for developing and maintaining the data architecture required to support clinical and business analyses and reporting. The director also supports ad hoc reporting for accreditation and regulatory compliance as well as automation of reporting for clinical operations. 19
27. Vice President of Operations: The vice president of operations reports to the president and is a member of the senior leadership team. The vice president of operations is responsible for direction and leadership of all company operations in order to provide service excellence. This includes overseeing claims and customer service operations and functions, including enrollees telephonic access to the organization, claims processing, and complaints, grievances, and appeals processes. The vice president is a member of the QMC, QIC, CQSC, appeals committee, and QCC. 30. Director of Customer Service: The director of customer service reports to the senior director of operations and is a member of the QIC and QCC. The director is responsible for the daily management of the enrollee and provider call center. This includes managing operations for, monitoring and reporting key organizational service statistics for areas including complaints, grievances, and appeals. The director institutes improvement activities as needed. 31. Vice President and Chief Marketing Officer: The vice president and chief marketing officer (CMO) reports to the president and is a member of the senior leadership team. The CMO is responsible for the direction and oversight of all marketing and communications operations, oversees enrollee acquisition and retention, enrollee and provider communications, and provider satisfaction surveys. The CMO also oversees business development opportunities. Committee memberships include QMC and CQSC. 32. Senior Director of Pharmacy: The senior director of pharmacy is a registered pharmacist who is responsible for overall pharmacy management services, including Network Health s Preferred Drug List, pharmacy policies and procedures, and management of pharmacy utilization and costs. The senior director interfaces with and coordinates pharmacy services with other internal departments within clinical affairs as well as Customer Service, IT and Marketing. The senior director serves as administrator for the pharmacy and therapeutics (P & T) committee, chairs the pharmacy planning committee and manages the relationship with the pharmacy benefit manager (PBM) and specialty pharmacy vendor. The senior director is a member of the quality improvement committee, the clinical quality steering committee, the utilization management committee and the quality concerns committee. The senior director supervises the manager of clinical pharmacy operations, clinical pharmacist and pharmacist for clinical pharmacy operations. The senior director of pharmacy reports to the chief medical officer. 33. Manager of Clinical Pharmacy Operations: 20
The manager of clinical pharmacy operations is a registered pharmacist who is responsible for day-to-day operations of the pharmacy Department. The manager of clinical pharmacy operations researches, approves and denies requests for medications consistent with medication request guidelines and pharmacy policies and procedures. The manager serves on the P & T committee and pharmacy planning committee and coordinates the day-to-day operational processes with the PBM. The manager of clinical pharmacy operations supervises pharmacy benefit coordinators and pharmacy intake/outreach coordinator and reports to the senior director of pharmacy. 34. Clinical Pharmacist: The clinical pharmacist is a registered pharmacist who is responsible for the establishment and maintenance of Network Health s Preferred Drug List (PDL). The clinical pharmacist develops drug monographs, therapeutic class reviews, and other appropriate materials to assist the P & T committee to review drugs for pharmacy benefit decisions. The clinical pharmacist ensures appropriate, safe, and cost-effective drug utilization by promoting therapeutic interchange, the selection of preferred medications, and pharmacy benefit restrictions, such as step care edits, quantity limits, and prior authorization. The clinical pharmacist develops criteria for medication request guidelines, and researches, approves and denies requests for medications consistent with medication request guidelines and pharmacy policies and procedures. The clinical pharmacist serves on the P & T committee and pharmacy planning committee and reports to the senior director of pharmacy. 35. Pharmacists for Clinical Pharmacy Operations: The pharmacist for clinical pharmacy operations is a registered pharmacist who is responsible for oversight of programs such as the specialty pharmacy program or the Medicare and Medicaid dually-eligible pharmacy program. The pharmacist develops drug monographs, therapeutic class reviews, and other appropriate materials to assist the P & T committee to review drugs for pharmacy benefit decisions. The pharmacist develops criteria for medication request guidelines, and researches, approves and denies requests for medications consistent with medication request guidelines and pharmacy policies and procedures. The pharmacist serves on the P & T committee and pharmacy planning committee and reports to the senior director of pharmacy. 36. Pharmacy Benefit Coordinators: The pharmacy benefit coordinators are certified pharmacy technicians who respond to pharmacy inquires received via the customer service department, telephone, fax, mail, secure email or secure website. The pharmacy benefit coordinator assists Enrollees, providers and pharmacies with the pharmacy benefit or program questions as well as pharmacy prior authorization requests. The pharmacy benefit coordinator documents and communicates prior authorization decisions to enrollees, providers and pharmacies according to pharmacy policies and procedures. Designated pharmacy benefit 21