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Form of workJob Description
Qualifications:
Qualifications: Education: Bachelor's degree in Health Care Administration, Public Health, Nursing, or related field or the equivalent combination of training and experience is required. Preferred/Desirable: Master's degree in related field strongly preferred. Experience: 10+ years progressively responsible experience in leading Quality Improvement Programs, which includes supervision of staff and budget management, is required. Comprehensive knowledge of Medicaid and MassHealth regulations, guidelines and standards is required. Comprehensive knowledge of accreditation organizations such as NCQA and URAC is required. Preferred/Desirable: Experience within a managed care organization is strongly preferred. Previous experience in designing and leading an accreditation process is strongly preferred. Certification or Conditions of Employment: Pre-employment background check Registered nurse with active license CPHQ certification required. Competencies, Skills, and Attributes: Comprehensive knowledge of UM standards and QM/QI standards, processes and metrics; including HEDIS, P4P, CAHPS, and CMS is required. Proven leadership skills and ability to build effective teams and direct the management of multiple, complex, high impact projects is required. Outstanding oral and written communication skills. Ability to build relationships and successfully interact with staff at all levels of the organization and with external constituencies. Working Conditions and Physical Effort: Regular and reliable attendance is an essential function of the position. Fast paced office environment. Work is normally performed in a typical interior/office work environment. No or very limited physical effort required. No or very limited exposure to physical risk.
Responsibilities:
Job Summary: Provides leadership for all activities relating to the development and management of the Plan's utilization management program, select medical management vendors, member appeals and grievances, and continuous Quality Improvement and accreditation activities including National Committee for Quality Assurance (NCQA), MassHealth Quality Goals, CMS, and clinical and operational quality programs. Oversees the Office of Clinical Affairs (OCA) project management functional area. Develops and oversees policies and processes to ensure implementation of programmatic initiatives, such as improved behavioral health and medical integration. Provides Quality Improvement, utilization management and medical management vendor expertise to corporate wide initiatives. Supports the Senior Director of Clinical and Quality Management and participates in developing and implementing business plans in the Clinical and Quality Management area to support the Plan's strategy. Key Functions/Responsibilities: Designs, implements and leads the Plan's continuous Quality Improvement infrastructure. Acts as an internal consultant and resource to all levels of the organization relative to CQI processes and standards. Keeps abreast of New Hampshire Department of Health and Human Services (DHHS), MassHealth and Commonwealth Care strategic goals to ensure processes, plans and policies are designed to fulfill strategic objectives, such as improved integration of Behavioral Health and medical management. Acts as an internal consultant and resource to OCA relative to UM program compliance. Leads all Plan activities in application for NCQA re-accreditation and addition of new products to current accreditation Represents the Senior Director of Clinical and Quality Management in various settings and has decision making authority on behalf of the Senior Director as requested by the Senior Director. Reviews and edits documentation (e.g. request for proposals) on behalf of the Senior Director of Clinical and Quality Management as directed Provides direction and mentoring to other directors within the Clinical and Quality Management area. As part of senior management in the Clinical and Quality Management area, participates in OCA strategic planning and provides Senior Director of Clinical and Quality Management and Chief Medical Officer with timely and accurate information. Interacts with the Executive Team and Core Executive Team on a regular basis to provide input and support Plan strategic initiatives. Responsible for UM program compliance with contractual requirements and accreditation standards. Responsible for member appeals and grievances to ensure compliance with contractual requirements and accreditation standards. Responsible for the ongoing administrative, clinical, fiscal and Programmatic interaction with NCQA, DHHS and MassHealth as it relates to CQI activities. Communicates with NCQA as needed to ensure the Plan is informed of all events and circumstances that affect the on-going achievement of NCQA accreditation. Ensures compliance with MassHealth contractual requirements relative to Quality Management / Quality Improvement, and MassHealth Quality Goals. Ensures compliance with DHHS, Connector and Division of Insurance contractual requirements relative to Quality Management / Quality Improvement. Directs quality of care studies (based on targeted areas for quality management and Quality Improvement). Oversees analysis of data, root cause analysis, plans for improvement, technical support to Plan managers, and re-measurement activities to assess performance improvement. Monitors quality performance indicators; prepares reports for quality oversight committees; develops vehicles to communicate performance to providers; and identifies clinical and administrative concerns for further investigation and analysis. Develops and manages communications with providers, government and accreditation organizations with respect to results of Quality management studies, including oversight of remedial action as required. Oversees the project management function for clinical areas within OCA. Supervises the Manager of OCA Project Management. Directs the supervision of subordinate Quality staff to include hiring, work allocation, scheduling, training and professional development, problem resolution, performance evaluation and related supervisory activities. Maintains budgetary responsibility for the department. Serves as the Official Record Keeper of the Quality Improvement Committee.
Qualifications:
Qualifications: Education: Bachelor's degree in Health Care Administration, Public Health, Nursing, or related field or the equivalent combination of training and experience is required. Preferred/Desirable: Master's degree in related field strongly preferred. Experience: 10+ years progressively responsible experience in leading Quality Improvement Programs, which includes supervision of staff and budget management, is required. Comprehensive knowledge of Medicaid and MassHealth regulations, guidelines and standards is required. Comprehensive knowledge of accreditation organizations such as NCQA and URAC is required. Preferred/Desirable: Experience within a managed care organization is strongly preferred. Previous experience in designing and leading an accreditation process is strongly preferred. Certification or Conditions of Employment: Pre-employment background check Registered nurse with active license CPHQ certification required. Competencies, Skills, and Attributes: Comprehensive knowledge of UM standards and QM/QI standards, processes and metrics; including HEDIS, P4P, CAHPS, and CMS is required. Proven leadership skills and ability to build effective teams and direct the management of multiple, complex, high impact projects is required. Outstanding oral and written communication skills. Ability to build relationships and successfully interact with staff at all levels of the organization and with external constituencies. Working Conditions and Physical Effort: Regular and reliable attendance is an essential function of the position. Fast paced office environment. Work is normally performed in a typical interior/office work environment. No or very limited physical effort required. No or very limited exposure to physical risk.
Responsibilities:
Job Summary: Provides leadership for all activities relating to the development and management of the Plan's utilization management program, select medical management vendors, member appeals and grievances, and continuous Quality Improvement and accreditation activities including National Committee for Quality Assurance (NCQA), MassHealth Quality Goals, CMS, and clinical and operational quality programs. Oversees the Office of Clinical Affairs (OCA) project management functional area. Develops and oversees policies and processes to ensure implementation of programmatic initiatives, such as improved behavioral health and medical integration. Provides Quality Improvement, utilization management and medical management vendor expertise to corporate wide initiatives. Supports the Senior Director of Clinical and Quality Management and participates in developing and implementing business plans in the Clinical and Quality Management area to support the Plan's strategy. Key Functions/Responsibilities: Designs, implements and leads the Plan's continuous Quality Improvement infrastructure. Acts as an internal consultant and resource to all levels of the organization relative to CQI processes and standards. Keeps abreast of New Hampshire Department of Health and Human Services (DHHS), MassHealth and Commonwealth Care strategic goals to ensure processes, plans and policies are designed to fulfill strategic objectives, such as improved integration of Behavioral Health and medical management. Acts as an internal consultant and resource to OCA relative to UM program compliance. Leads all Plan activities in application for NCQA re-accreditation and addition of new products to current accreditation Represents the Senior Director of Clinical and Quality Management in various settings and has decision making authority on behalf of the Senior Director as requested by the Senior Director. Reviews and edits documentation (e.g. request for proposals) on behalf of the Senior Director of Clinical and Quality Management as directed Provides direction and mentoring to other directors within the Clinical and Quality Management area. As part of senior management in the Clinical and Quality Management area, participates in OCA strategic planning and provides Senior Director of Clinical and Quality Management and Chief Medical Officer with timely and accurate information. Interacts with the Executive Team and Core Executive Team on a regular basis to provide input and support Plan strategic initiatives. Responsible for UM program compliance with contractual requirements and accreditation standards. Responsible for member appeals and grievances to ensure compliance with contractual requirements and accreditation standards. Responsible for the ongoing administrative, clinical, fiscal and Programmatic interaction with NCQA, DHHS and MassHealth as it relates to CQI activities. Communicates with NCQA as needed to ensure the Plan is informed of all events and circumstances that affect the on-going achievement of NCQA accreditation. Ensures compliance with MassHealth contractual requirements relative to Quality Management / Quality Improvement, and MassHealth Quality Goals. Ensures compliance with DHHS, Connector and Division of Insurance contractual requirements relative to Quality Management / Quality Improvement. Directs quality of care studies (based on targeted areas for quality management and Quality Improvement). Oversees analysis of data, root cause analysis, plans for improvement, technical support to Plan managers, and re-measurement activities to assess performance improvement. Monitors quality performance indicators; prepares reports for quality oversight committees; develops vehicles to communicate performance to providers; and identifies clinical and administrative concerns for further investigation and analysis. Develops and manages communications with providers, government and accreditation organizations with respect to results of Quality management studies, including oversight of remedial action as required. Oversees the project management function for clinical areas within OCA. Supervises the Manager of OCA Project Management. Directs the supervision of subordinate Quality staff to include hiring, work allocation, scheduling, training and professional development, problem resolution, performance evaluation and related supervisory activities. Maintains budgetary responsibility for the department. Serves as the Official Record Keeper of the Quality Improvement Committee.
