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 an Annual Quality Improvement Work Plan
Develop an Annual Evaluation of the Quality Improvement Program and activities
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:
Progressive administrative/operations leadership experience in a managed care environment, particularly with Medicare Advantage Plans and SNPs
Knowledge of statistical and methodological procedures
Demonstrated leadership skills in program execution and people management
Master's degree preferred in health administration or health care quality management OR BS/BA Degree and 10-15 years of work experience in the health administration field with managed care and quality improvement experience
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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Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Quality Assurance
Industries
Internet Publishing
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