Plans, develops and directs Quality Improvement functions and activities. Provides leadership necessary to achieve national best practice performance levels in quality improvement programs while implementing evidence based medicine/practice solutions. Ensures that the quality of healthcare services rendered meets or exceeds professionally recognized national and 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.
Reports to: State President Dept.: Heath Services QI Location: Atlanta, GA
Develops and implements the quality improvement plans and activities within national/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 teams with overall responsibility for providing support for clinical quality initiatives and regulatory/contractual requirements. Support includes telephonic and in-person outreach as identified as requiring outreach. In addition, to provide assistance to clinical compliance staff with member education, 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.
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
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
Licenses and Certifications: A license in one of the following is required:
Required Other For FL/IL/MO/NJ/NE, a current unrestricted RN license
Preferred Licensed Registered Nurse (RN)
Preferred Cerified Professionals 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 Microsoft Access
Required Intermediate Healthcare Management Systems (Generic)