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Organizational Structure of The QI Program

Governing Body

The Horizon Board of Directors holds the final authority and accountability for the quality of care and service provided to Horizon members. The Board of Directors of Horizon Blue Cross Blue Shield of New Jersey and Horizon Insurance Company have delegated quality improvement responsibility and authority to the Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board meets at least three times a year and provides oversight to the Quality Improvement Program through reviewing and approving annually, the Quality Improvement Program Description, Work Plan, and Evaluation. In turn, the Boards of Directors of the Horizon companies also review and approve annually the Quality Improvement Program Description, Work Plan and Evaluation. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board has designated full responsibility for the Horizon Quality Improvement Program to the Quality Improvement Committee (QIC). The QIC provides oversight and evaluation of the Quality Improvement Program.


Quality Committee of the Board

The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board is chaired by the VP and Chief Medical Officer for Horizon Blue Cross Blue Shield of New Jersey, who has full responsibility and authority for the quality of care provided to Horizon members.

The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board meets at least three times a year and provides oversight to the Horizon Quality Improvement Program through reviewing and approving annually the Quality Improvement Program Description, Work Plan and Evaluation. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board reports to the Board of Directors of Horizon Healthcare of New Jersey, Inc. Annually, the Horizon Board reviews and approves the Quality Improvement Program Description, Work Plan and Evaluation. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board has delegated full responsibility for Horizon’s Quality Improvement Program to the QIC.

Quality Improvement Committee


The QIC is an interdisciplinary committee that reviews, analyzes, recommends and approves all Quality Improvement activities for the following lines of business: Commercial HMO, POS, Omnia, Direct Access, EPO, PPO, FEHBP, Traditional, self-funded accounts, including SHBP, and QHP products.

The QIC reports at least three times per year to the Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board of Directors. The Board of Directors of the Horizon companies have the ultimate final authority and accountability for all Quality Improvement activities relating to the health plans mentioned above that are operated under their direction.

The Vice President and Chief Medical Officer (CMO) of Horizon Blue Cross Blue Shield of New Jersey, or their designee, serves as Chairperson. The CMO has designated the Senior Medical Director, Medical Management, to serve as Chairperson of the Quality Improvement Committee.

QIC Committee Composition

The Committee consists of the chairpersons of the reporting committees and directors from functional areas involved in service and clinical quality improvement initiatives. At a minimum, this includes:

  • Senior Medical Director, Medical Management (tie breaker)
  • Chairpersons of all of the reporting Committees (up to 12 voting members). Chairpersons must be Medical Directors or at the Director level or above to be members of the QIC however, they may appoint a designee to attend in their absence. If a Committee Chairperson is not at the Director level, that Chairperson’s Director is the designated voting member for the QIC.
  • Participating Physicians (up to 5 as voting members including external network physicians)
  • Director, Quality Performance and Stars (1 voting member)
  • Director, Service Operations (1 voting member)
  • Director, Market Business Units (1 voting member)
  • Director, Clinical Operations (1 voting member)
  • Director, Pharmacy Programs (1 voting member)
  • Assistant General Counsel (non-voting member)
  • Director, Compliance Services (1 voting member)
  • Director, Clinical Initiatives (1 voting member)
  • Executive Medical Director of Population Health & Transformation (1 voting member)
  • Director, Network Management (1 voting member)
  • Director, Clinical Behavioral Health Services (1 voting member)
  • Medical Director, Behavioral Health (1 voting member)

Terms of Office

The QIC Chairperson appoints committee members to serve a one (1) year term of office. Members will be considered for re-appointment annually. There is no limitation on the number of terms of reappointment a committee member may have.

Others Attending

Other medical and non-medical personnel and consultants may attend and participate without vote as needed.

Participating physicians, as necessary, will be invited on a regular basis to ensure involvement of the medical community.

Frequency of Meetings/Voting/Quorum

The QIC meets quarterly. Attendance records are maintained. Voting privileges are not assigned to alternates attending in place of committee members. A majority of the committee’s membership must be present to meet the quorum requirement (50% + 1). Members not in attendance at four (4) prescheduled meetings in any twelve-month period may be removed / replaced through action by the chairperson. Action is taken by the majority vote of members present.


Minutes are recorded under the direction of the chairperson. Copies of the minutes are distributed to committee members. All preliminary research on agenda items is completed prior to the meeting and documentation released with the agenda one week in advance of the meeting. Members review all materials prior to the meeting date. The approved actions are forwarded to the Quality Committee of the Board of Directors. Approved committee minutes are maintained in a binder and in an on-line database.


Member, physician and provider confidentiality is maintained. All external, non-employee members of the QIC must sign a confidentiality agreement annually. All internal members must comply with Horizon policies.


  • The QIC is responsible for the annual development and implementation of the Quality Improvement Program, oversight of the QI Work Plan (QIWP) and analysis and approval of the QI Program Evaluation.
  • The QIC monitors on a quarterly basis the QIWP, which details goals and objectives with established timetables and criteria for completion. These goals will involve specific medical policy, practice guidelines, health care evaluation and utilization, clinical and service quality assessments, as per applicable regulatory and accreditation requirements and in alignment with Horizon’s quality metrics.
  • The QIC conducts a more focused review of any topics that it deems necessary by tracking and trending performance indicators.
  • The QIC is responsible for annual approval of the Quality Improvement and Medical Management Program Descriptions, Work Plans and Program Evaluation.
  • The QIC serves as the coordinating body that reviews and approves the recommendation of the committees that report to it: Clinical Policy Committee, Quality Case Review Committee, Medical Management Committee, Provider Appeals Committee, Member Appeals Committee, Delegate and Vendor Oversight Committee, Credentials Committee, Member Appeals Committee-Benefit Issues Complaints Committee, Pharmacy and Therapeutics Committee, Member Provider Service Satisfaction Committee and Quality Advisory Committee.
  • The QIC is responsible for approval of all committee actions, whether submitted on an annual work plan or in the quarterly reports. The QIC may request or recommend action plans from the committees as needed.
  • The committees will report to QIC on a quarterly basis. Items requiring action on a more frequent basis will be presented to the QIC as needed.
  • The QIC delegates the approval of policies, procedures, workflows and guidelines to the respective committees.
  • The QIC directs and evaluates all statewide ongoing activities pertaining to the quality of clinical care, services to members and utilization of resources.
  • The QIC recommends, approves and oversees new Quality Improvement activities.
  • The QIC ensures that Horizon complies with appropriate accrediting organizations and regulatory requirements.

The following represents a list and description of the committees:

Inclusion of Participating Providers in the QI Program

Participating providers are included as voting members of the QIC. Participating providers are also voting members of the Horizon Medical Management Committee, Pharmacy and Therapeutics Committees, and Quality Peer Review Committee. Participating physicians and other providers are kept informed about the written QI Program Description available in provider newsletters and on the plan’s website. Providers can also access information in the Provider Administrative Manual about how they can be included in the design, implementation, review and follow up of Commercial QI activities.

Quality Program Organizational Structure

Review the organizational structure of the QIC.

Quality Improvement Program Resources

Resources available to the Program that contribute to the Quality Improvement function include various Horizon departments, including Quality Management, Medical Management (Utilization Management, Case Management and Care Management Programs), Marketing, Service, Communications, Operations, Information Systems, Credentialing, Service Quality, Pharmacy and Network Management. Organizational charts are used to provide a more comprehensive description of the resources available within each department.

Roles and Responsibility-Individual

External Quality Review

Horizon’s healthcare plans are accredited by the National Committee for Quality Assurance (NCQA). Accreditation is a rigorous assessment of Horizon’s systems, clinical quality, member satisfaction, policies and procedures. The Quality Management Department is responsible for educating staff on annual updates to the standards, assisting teams with document preparation, completing gap analysis, the submission of documentation and the coordination of the NCQA survey. The Division of Banking and Insurance (DOBI) monitors member enrollments, regulation compliance and market structure to ensure product availability in the New Jersey marketplace.

Data Sources

Horizon utilizes data from the following sources to identify opportunities for improvement, track and measure process, outcomes and overall effectiveness. These data sources include, but are not limited to:

  • Annual HEDIS® reports
  • Quality Rating System (QRS)
  • Member Satisfaction Survey (CAHPS®)
  • Enrollee Experience Survey (EES)
  • Provider satisfaction surveys (Office Manager/Physician)
  • Hospital acquired conditions
  • Member and provider files
  • Medical record review data
  • Access and availability data (GeoAccess)
  • Continuity and coordination of care processes and data
  • Clinical and preventive guidelines
  • Credentialing and re-credentialing data and files
  • Marketing information
  • Member quality of care complaints
  • Member complaints and appeals
  • Provider complaints and appeals
  • Chronic care program data and files
  • Case management data and files
  • Utilization management data and files
  • Delegated entities’ performance data
  • Internal audits of Quality Improvement processes data and reports
  • Pharmacy utilization data
  • Phone statistics (ASA, CAR)
  • Employer satisfaction survey
  • Concurrent review database
  • 24/7 nurse line data and reports
  • Online interactive tools/HRA data and reports
  • Feedback from external regulatory and accrediting agencies
  • Office site visits reports

All data is stored in Horizon’s electronic systems. Utilization and member/provider data is stored, updated and maintained in an Enterprise Data Warehouse that is backed up daily. Data resulting from surveys, interaction with members, mandatory reporting and specific analysis and monitoring are stored in independent databases supported by the enterprise IT Department, which in turn ensures data confidentiality in compliance with HIPAA regulations.

Data accuracy is assessed through periodic audits such as medical record reviews for performance monitoring and reporting, sharing of performance data with providers and other internal audit processes.

Data collection, management and analysis is carried out by Horizon’s staff including nurses, business analysts, reporting analysts and clinical auditors with the appropriate background and qualifications.

A comprehensive data recovery process is in place to ensure continuity of business in the event of a major adverse event. All data is backed-up daily and stored in an outside location. A recovery site is located 40 miles from the corporate headquarters in Newark where Horizon’s technology (telephone and computers) can be rerouted in the event of a major disruption of business. Horizon has a work-at-home policy and several locations which contribute to a fast restoration of services in the event of a major adverse event.

All data, documents, reports, materials, files and committee minutes are kept for a period of years (according to various regulatory, state and federal requirements), whether on site or achieved in a secured site. Horizon has a “Records Management Policy” reviewed annually that clearly describes these processes.

Behavioral Health

The Behavioral Health Program offers quality services to help members manage all aspects of their health and provides access to mental health and substance abuse services in a variety of settings by participating providers from several disciplines. Behavioral Health Case Managers provide assessment, development and implementation of individualized plans of care and offer coordination of integrated physical and behavioral health care services for members and their families. The program utilizes the Care Radius medical management system to support delivery and documentation of the case management process.

Horizon is committed to monitoring and improving the quality of Behavioral Healthcare (BH), as needed, with the development of BH specific activities that are incorporated into the QI work plan. They include core performance indicators, monitoring and intervention activities designed to focus on the safety and quality of services provided to members, and coordination of care for members. Work plan goals are evaluated annually with achievements and opportunities for improvement specified in the organization’s annual program evaluation. To ensure continuity and coordination of care/integration between behavioral and physical healthcare services, BH clinicians and business owners participate in the applicable committees noted in the QI organizational structure.

Additionally, the Network Contracting and Servicing and Network Operations Departments review geographical access reports that address the adequacy of the behavioral health provider network as well as reports which assess member ability to access behavioral services in a timely manner. Deficiencies are acted on to reduce barriers to care and ensure continuity of care for members.