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.
Department: State, Health Services, Quality Improvement
Reports to: State, Chief Operating Officer
Location: Atlanta, GA
- Develops and implements the quality improvement plan within regional markets 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.
- 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.
- Supervises 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 regional market performance data, identifies opportunities for improvement, and presents findings quarterly to the Performance 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.
- Supervises QI Specialists 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, Public Health, Health Administration or directly related field
- Preferred A Master's Degree in a related field
- Required 10 years of experience in directly related Quality Improvement job duties
- Required 5 years of experience in managed healthcare
- Required 5 years of management experience
- Required Other Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards
- Preferred Other Experience in Medicaid/Medicare
Licenses and Certifications:
- Advanced 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 Ability to effectively present information and respond to questions from peers and management
- Advanced Ability to communicate and make recommendations to upper management
- Advanced Ability to lead/manage others
- Advanced Ability to drive multiple projects
- Advanced Demonstrated leadership skills
- Required For FL/IL/MO/NJ/CA, a current unrestricted RN license
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Visio
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Access
- Required Intermediate Healthcare Management Systems (Generic)