Onsite-Not a Remote Position
Position Purpose: This leadership position is responsible for the development, implementation and oversight of the Quality Improvement Program, related work plans, quality activities, HEDIS, and STARS. This leader will develop, implement and monitor all quality assurance and performance improvement activities within the organization. Direct responsibility for the Quality Improvement Program (QIP) which includes a comprehensive, integrated, and on-going system designed to objectively and systematically monitor and evaluate the quality and appropriateness of clinical and non-clinical care and services provided to members.
Key Responsibilities:
- Responsible for ensuring compliance with all State, CMS, AHCA, and any other regulatory agency.
- Responsible for the oversight of the Quality Improvement Department including training and developing the team.
- Responsible for managing the operations of the Quality of Care / Quality of Service Grievance Department.
- Ensure systematic identification and follow-up of potential quality/compliance issues.
- Voting member of the Quality Improvement Committee, Appeals and Grievance Committee, and Medical Management Committee.
- Responsible for quarterly reporting to the Quality Improvement Committee, governmental agencies and any other regulatory agencies as needed.
- Responsible for all interviews and hiring of department.
- Responsible for the development of policies and procedures to ensure regulatory compliance including HIPAA requirements.
- Develops and monitors corrective action plans required by regulatory agencies.
- Works closely with the medical staff, administration and participates in committees as needed.
- Knowledge of current Medicare Advantage and health plan operational and regulatory guidelines established by CMS, AHCA and other federal and state regulatory guidelines.
- Ability to work well under pressure and in difficult situations.
- Capable of managing a variety of complex issues while driving momentum of key initiatives.
- Extensive experience in developing and implementing policies, procedures and programs for departmental as well as organizational-wide use, including those which must comply with NCQA, AAAHC, State and Federal guidelines.
- Proactive pursuit of methods to improve care and service to members through implementation of quality improvement studies and projects.
- Educate staff, members, physicians, hospitals, and ancillary providers about the Plan’s goals, objectives and structure for providing quality, cost effective, and coordinated managed health and mental health care.
- Promote open communication and interaction between providers, staff and members regarding the organization’s quality improvement and assurance efforts.
- Develop annually: Quality Improvement Work Plan, Annual Program Evaluation and Program Description.
- Compile systematic reports for internal and external distribution regarding quality assurance and performance improvement activities and studies.
- Respond to requests from the Quality Improvement Committee and the Board of Directors regarding quality related issues/concerns.
- Establish and maintain open communication with state and federal officials regarding quality assurance issues and changes in state and federal regulations.
- Perform other job-related duties as assigned from time to time.
Qualifications:
- Master's degree preferred in health administration or health care quality management OR BS/BA Degree and 10+ years progressive experience with a managed care organization with emphasis on HEIDIS/STARS and quality improvement.
- 5+ years prior experience in a supervisory role with responsibilities for hire, termination and evaluation of team members performance.
- Progressive administrative/operations leadership experience in a managed care environment, particularly with Medicare Advantage Plans and SNPs.
- Knowledge of Center of Medicare & Medicaid Services (CMS) rules and regulations related to Medicare Advantage programs.
- Knowledge of Medicare Advantage, operating requirements and processes and compliance expectations.
- Demonstrates clinical proficiency with healthcare performance measures including HEDIS, Medicare Stars, Pharmacy Quality Alliance (PQA) and Medicare specific measures.
- Knowledge of current and evolving NCQA HEDIS Technical Specifications and other state specific clinical measures.
- Previous experience coordinating and overseeing HEDIS medical record review, supplemental data collection and other activities that support annual HEDIS project.
- Experience communicating with a high level of expertise and professionalism with regulators, auditors, providers, vendors, executives and other stakeholders.
- Previous quality improvement directorial experience.
- Proven track record of strategic planning and program development.
- Knowledge of statistical and methodological procedures.
- Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.
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