Plans, develops and directs the Quality Improvement functions. Provides leadership necessary to achieve national best practice performance levels in quality improvement while implementing evidence based medicine/practices. Ensures that the quality of healthcare services rendered meets or exceeds professionally recognized community standards. Interfaces with a diverse range of clinical and administrative professionals, resolves sometimes-complex policy and service issues within the group and directs data analytic and reporting activities that are prescribed by customers and regulators in a complex environment. Ensures compliance with state, federal and accreditation requirements.
- Develops and implements quality improvement plan in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards.
- Establishes professional relationships with state, stakeholders and community agencies to facilitate quality process internally and externally.
- Develops and implements systems, policies, and procedures for the identification, collection, and analysis of performance measurement data.
- Analyzes, updates, and modifies standard operating procedures and processes to continually improve QI Department services/operations including but not limited to quality of care complaint/adverse event investigations, and ambulatory medical record review assessments.
- Assists in strategizing and facilitating various committee structures and functions to best address the QI process and oversees Quality Committees.
- Oversight and interface internally and externally with pay for performance programs and initiatives.
- Coordinates and completes all QI activities required to meet national accreditation and regulatory performance improvement initiatives.
- Collaborates with corporate and/or market member outreach coordinators with overall responsibility for providing support for clinical quality initiatives and regulatory/contractual requirements. Support includes telephonic and in-person outreach to members who are identified as requiring outreach services. In addition, to provide assistance to clinical compliance staff with member education classes, quality management, and Health Promotion initiatives and performance data collection and recording.
- Collects and summarizes market performance data, identifies opportunities for improvement, and presents findings quarterly to the Quality Improvement Committee.
- Develops strategies for special program participation and Quality Improvement. Develops systems for close coordination of QI related functions with departments whose activities are directly a part of the QI Program, including Credentialing.
- Oversees QI staff in the implementation of performance initiatives to drive HEDIS performance and contract compliance quality performance.
- Communicates new state, federal and third party regulations and requirements to the staff.
- Facilitates strategic and tactical planning for the quality improvement program, including needs assessments, evaluations, root cause analysis and interventions.
- Collaborates with Health Services, Operations, and Information Technology departments to ensure full integration of quality improvement reporting for contract and accreditation compliance.
- Participates in site visit preparation and execution by regulatory and accreditation agencies (state agencies, URAC, NCQA, CMS, AAAHC, EQRO).
- Leads, facilitates, and advises internal quality improvement teams.
- Actively participates on, or facilitates committees such as: Quality Improvement, Utilization Management, Patient Safety and Risk Management.
- Responsible for monitoring and evaluating staff performance.
- Performs other duties as assigned.
This position is contingent upon the bid award in the state of New Mexico to WellCare Health Plans, Inc.-SM1
- A Bachelor's Degree in HealthCare, Nursing, Public Health, Health Administration or directly related field required.
- A Master's Degree in a related field preferred.
- 7 years of experience in Quality Improvement required.
- 5 years of experience in managed care required.
- 4 years of management experience required.
- Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards required.
- Knowledge of community, state and federal laws and resources.
- Demonstrated written communication skills.
- Demonstrated interpersonal/verbal communication skills.
- Demonstrated analytical skills.
- Demonstrated problem solving skills.
- Ability to multi-task.
- Ability to work in a fast paced environment with changing priorities.
- Ability to effectively present information and respond to questions from families, members, and providers.
- Knowledge of healthcare delivery.
- Ability to effectively present information and respond to questions from peers and management.
- Ability to lead/manage others.
- Demonstrated leadership skills.
- Ability to implement process improvements.
- Ability to influence internal and external constituents.
Licenses and Certifications:
A license in one of the following is required:
- For FL/IA/IL/MO/NJ/CA/NE, a current unrestricted Registered Nurse (RN) License required.
- All other states, a licensed Registered Nurse (RN) preferred.
- For Nebraska: Certified by the National Association for Health Care Quality, or certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and the Utilization Review Providers required.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- Intermediate proficiency in Microsoft Outlook, Word, Excel, PowerPoint, and Visio.
- Intermediate proficiency in a Healthcare Management System software.