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Quality Improvement Director

3 months ago

Miami, United States DOCTORS HEALTHCARE PLANS, INC. Full time
Job DescriptionJob Description

Position Purpose: This leadership position is responsible for the development, implementation and oversight of the Quality Improvement Program, related work plans, quality activities, HEDIS, and STARS.  This leader will develop, implement and monitor all quality assurance and performance improvement activities within the organization.  Direct responsibility for the Quality Improvement Program (QIP) which includes a comprehensive, integrated, and on-going system designed to objectively and systematically monitor and evaluate the quality and appropriateness of clinical and non-clinical care and services provided to members.

Key Responsibilities:

  • Responsible for ensuring compliance with all State, CMS, AHCA, and any other regulatory agency.
  • Responsible for the oversight of the Quality Improvement Department including training and developing the team.
  • Responsible for managing the operations of the Quality of Care / Quality of Service Grievance Department.
  • Ensure systematic identification and follow-up of potential quality/compliance issues.
  • Voting member of the Quality Improvement Committee, Appeals and Grievance Committee, and Medical Management Committee.
  • Responsible for quarterly reporting to the Quality Improvement Committee, governmental agencies and any other regulatory agencies as needed.
  • Responsible for all interviews and hiring of department.
  • Responsible for the development of policies and procedures to ensure regulatory compliance including HIPAA requirements. 
  • Develops and monitors corrective action plans required by regulatory agencies.
  • Works closely with the medical staff, administration and participates in committees as needed.
  • Knowledge of current Medicare Advantage and health plan operational and regulatory guidelines established by CMS, AHCA and other federal and state regulatory guidelines.
  • Ability to work well under pressure and in difficult situations.
  • Capable of managing a variety of complex issues while driving momentum of key initiatives.
  • Extensive experience in developing and implementing policies, procedures and programs for departmental as well as organizational-wide use, including those which must comply with NCQA, AAAHC, State and Federal guidelines.
  • Proactive pursuit of methods to improve care and service to members through implementation of quality improvement studies and projects.
  • Educate staff, members, physicians, hospitals, and ancillary providers about the Plan’s goals, objectives and structure for providing quality, cost effective, and coordinated managed health and mental health care.
  • Promote open communication and interaction between providers, staff and members regarding the organization’s quality improvement and assurance efforts.
  • Develop an Annual Quality Improvement Work Plan.
  • Develop an Annual Evaluation of the Quality Improvement Program and activities.
  • Compile systematic reports for internal and external distribution regarding quality assurance and performance improvement activities and studies.
  • Respond to requests from the Quality Improvement Committee and the Board of Directors regarding quality related issues/concerns.
  • Establish and maintain open communication with state and federal officials regarding quality assurance issues and changes in state and federal regulations.
  • Perform other job-related duties as assigned from time to time.

Qualifications:

  • Progressive administrative/operations leadership experience in a managed care environment, particularly with Medicare Advantage Plans and SNPs
  • Start-up experience in a managed care environment
  • Previous quality improvement directorial experience
  • Experience in strategic planning and development
  • Knowledge of statistical and methodological procedures
  • Demonstrated leadership skills in program execution and people management
  • Master's degree preferred in health administration or health care quality management  OR BS/BA Degree and 10-15 years of work experience in the health administration field with managed care and quality improvement experience

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

No Third Party Agencies or Submissions Will Be Accepted.   

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP   

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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