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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 coporate and/or maket 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
Required A Bachelor's Degree in HealthCare, Nursing, Publich Health, Health Administration or directly related field
Preferred A Master's Degree in a related field
Required 7 years of experience in Quality Improvement
Required 5 years of experience in managed care
Required 4 years of management experience
Required Other Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards
Intermediate Knowledge of community, state and federal laws and resources
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Advanced Demonstrated analytical skills
Advanced Demonstrated problem solving skills
Advanced Ability to multi-task
Advanced Ability to work in a fast paced environment with changing priorities
Advanced Ability to effectively present information and respond to questions from families, members, and providers
Advanced Knowledge of healthcare delivery
Advanced Ability to effectively present information and respond to questions from peers and management
Advanced Ability to lead/manage others
Advanced Demonstrated leadership skills
Advanced Ability to implement process improvements
Advanced Ability to influence internal and external constituents
Licenses and Certifications: A license in one of the following is required:
Required Other For FL/IA/IL/MO/NJ/NE, a current unrestricted RN License
Required Other Required in 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
Preferred Licensed Registered Nurse (RN)
Preferred Certified Professional in Healthcare Quality (CPHQ)
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Word
Required Intermediate Microsoft Visio
Required Intermediate Microsoft PowerPoint
Required Intermediate Microsoft Outlook
Required Intermediate Healthcare Management Systems (Generic)