Vp, Enterprise Quality, Strategy & Operations

Company :
Highmark HealthJob Description :
JOB SUMMARY
This job is responsible for establishing the Highmark Health Quality, Safety & Value (QSV) Strategy & Operations plan aligned with organizational goals, regulatory requirements, and population health priorities. The incumbent is expected to ensure integration across the enterprise and to uphold the quality, safety, and value vision for our members and patients. The incumbent will work collaboratively across matrixed teams with Clinical and Quality Leadership at AHN, Highmark Health, and Highmark Inc. to drive and execute the quality strategy across the enterprise.. The incumbent will also champion a culture of excellence across our health plan and provider footprint, optimizing care delivery and financial performance while prioritizing patient safety and delivering exceptional value.
ESSENTIAL RESPONSIBILITIES

• Develop and implement a comprehensive QSV strategy aligned with organizational goals, regulatory requirements, and population health priorities.
• Lead c cross functional initiatives to improve quality and optimize resource utilization across the continuum of care.
• Develop and maintain robust performance measurement and data analytics capabilities to monitor outcomes, identify areas of improvement and track progress against the enterprise goals.
• Proactively work with market and segment leaders and their teams to establish bi-directional feedback and maximize performance improvement activities.
• Lead the implementation of evidence-based practices and risk mitigation strategies across Highmark and the footprint provider landscape.
• Oversee and ensure compliance with quality regulations, including NCQA, HEDIS, CMS and state specific requirements.
• Foster collaboration and build strong relationships with multiple stakeholders at Highmark as well as clinical and quality leadership across our provider landscape to drive enterprise initiative performance.
• Effectively communicate QSV performance data and insights to internal and external stakeholders, including boards, regulators, and leadership teams.
• Monitor best practices and trends, proactively identifying and integrating solutions to optimize QSV performance.
• Works under the leadership of the Highmark health plan CMO to drive the evolution of the QSV Dashboard as the Living Health Strategy Evolves.
• Own the Clinical Data Strategy inclusive of interoperability requirements and use of artificial intelligence to facilitate electronic clinical data acquisition and value.
• Collaborate proactively with dyad quality leaders across the organization.
• Ensures quality strategic framework is integrated into the enterprise Population Health Clinical Model Programming to demonstrate the wholistic achievement of better health outcomes.
• Ensures the business has the appropriate capabilities, people, processes, and technology in place to effectively execute.
• Serve as subject matter expert and consultant to the internal organization and providers in clinical quality matters.
• Identifies opportunities to streamline and rationalize redundancies across the organization. Responsible for achieving quality goals related to Centers for Medicare and Medicaid Services (CMS) STARS rating measures for both the Health Plan and AHN, in collaboration with the VP Government Quality and AHN quality leadership.
• Ensure development, maintenance, revision and promulgation of corporate medical policies, for all products and markets in accordance with regulatory requirements and in support of overall quality goals and objectives (e.g. Medicare STARS).
• Lead and evolve teams responsible for internal quality audits and quality gap closure initiatives.
• Perform management responsibilities to include but are not limited to, hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

EXPERIENCE
Required

• 10+ years in healthcare leadership with at least 5 years in a senior quality role within an integrated payer provider environment.
• Proven track record of success in leading and implementing QSV initiatives that deliver measurable improvement in QSV outcomes.
• Strong understanding of payer and provider perspectives and challenges.
• Demonstrated success in a dual role of Strategy & Execution
• Experience working with quality governing & regulatory bodies including but not limited to HEDIS and NCQA

Preferred

• Integrated payer provider System Quality Experience
• Medical Policy Experience
• Lean Six Sigma and/or Process Improvement
• Comfortable working in Matrix Environments

SKILLS

• Medicare Advantage
• Lean/Six Sigma Healthcare
• Leading Change
• Written & Oral communication skills.
• Demonstrated ability to build trust and lead by influence.
• Influence and Persuasion
• Execution Oriented
• Continuous Improvement
• Analytical and Logical Reasoning/Thinking
• Regulatory Compliance

EDUCATION
Required

• Bachelor's Degree

Substitutions

• None

Preferred

• Master's degree in public health, administration, or Medical Management
• Bachelor's degree in nursing or other Clinical Program

LICENSES or CERTIFICATIONS
Required

• Six Sigma and/or IHI certification
• Certified Case Management (CCM)

Preferred

• Certified Professional In Healthcare Quality (CPHQ)
• RN or MD

Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office
Teaches / trains others
Occasionally
Travel from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
No
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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