Director of Quality Improvement Initiatives - Health Plan

Location: Fort Lauderdale, FL
Date Posted: 02-01-2018
CareNational
Director of Quality Improvement Initiatives (HEDIS®/STARS/CAHPS) - Managed Care
Fort Lauderdale, FL
 
Your Job Summary: 
 
The Director of Clinical Quality Improvement Initiatives - Medicare is responsible for strategically developing and coordinating Quality Improvement Program-related activities, objectives, and analysis within the health plan. The Manager of QI provides ongoing maintenance and evaluation of systems and strategies to support the improvement of quality management accreditation through promoting and supporting innovation.  Responsible for ensuring compliance and providing direction and guidance for National Committee for Quality Assurance (NCQA) accreditation. The Manager will lead and direct process improvement activities that provide more efficient and streamlined workflow.
 
Your Benefits: 

EXCELLENT BENEFITS AND HIGHLY COMPETITIVE SALARY OFFERED!
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.

Your Background:
 
Prefer (but does NOT require) a Registered Nurse (R.N.) license.
Bachelor of Science in Nursing, Healthcare or Business Administration, or related field required; Master’s degree a plus.
Certified Professional in Healthcare Quality (CPHQ) is highly preferred.
Roughly 7-10 years’ experience in health insurance, health plan, health care quality management, or related field required.
Minimum of 4-5 years Managed Care Quality Improvement experience, including metric reporting and NCQA accreditation.
Around 3-4 years of progressive staff supervision or management experience, including project management and vendor oversight.
Strong working knowledge of Quality Improvement initiatives in a Managed Care environment is required.
Extensive knowledge of Medicare, Medicaid and similar state health programs, their regulatory guidelines, benefit management and coverage determination, reconsideration, and appeal processes.
Knowledge of Center for Medicare/Medicaid Services, requirements for Special Needs Plans (SNP), Medicare Medicaid Plans (MMP) and NCQA oversight requirements preferred.
Ability to analyze and integrate information and make sound decisions based upon established guidelines.
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
Experience in training, teaching, and coaching staffs to meet operational requirements and goals.
Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.

Your Duties:
 
Responsible for leading and collaborating with others on National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance.  Establishes strategic plans, policies, and procedures at all levels to ensure quality programs will meet or exceed guidelines or requirements and are consistent with overall quality strategies.  Ensures compliance with federal, state, and accreditation standards by developing, implementing and maintaining compliance processes within the department.  Maintains effective documentation of research programs to meet regulatory and Accreditation Standards. Provides oversight to assure accurate and complete quantitative analysis of clinical data, presentation of results of data analysis. Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.  Promotes plan-wide understanding, communication, and coordination of QM programs.
The scope of quality improvement for this position is primarily overseeing NCQA accreditation, and requested reports and projects.  The position will also provide oversight of other quality measures, such as STARS, HEDIS, and CAHPS/HOS.  Responsible for ensuring compliance and providing direction and guidance on clinical quality improvement and management programs including NCQA, URAC, or general accreditation.  Responsible for the reporting and analyzing of member care quality and for the development of plans and programs to support continuous quality improvement.  Acts as the liaison with government entities involved in accreditation and Performance Improvement projects.  In addition, the Director is responsible for establishing and monitoring procedures for receiving, investigating and responding in writing to member and provider grievances and appeals involving the review of clinical information. 
Maintains highly effective staff by selecting, developing, and training employees; communicating job expectations and monitoring job results; counseling and coaching employees; and by initiating, coordinating, and enforcing systems, policies, and procedures.  Work collaboratively with key health care professionals toward identification of opportunities for improvement, trend analysis, education and development of appropriate action plans for problem resolution.  Serve as a resource and leader working with research staff in study design, data collection, analysis, and reporting activities that support quality improvement interventions, transparency, compliance regulatory standards, and provider performance monitoring.  Ensure QM departmental policies and procedures are updated at least annually, new policies are developed as needed, and that all staff members are appropriately trained in updates.  Represents QM department by participating in assigned committees and interdisciplinary workgroups.  Serves as resource for internal and external customers including Medical Directors and provider organizations. 


“HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).”
AMANDA SOWARDS
SEARCH CONSULTANT
CareNational

amanda@carenational.com
443.552.7423 (CALL – TEXT – FAX)
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