Director of Quality Improvement

4 weeks ago


Miami, Florida, United States DOCTORS HEALTHCARE PLANS, INC. Full time
Job Summary

Doctors Healthcare Plans, Inc. is seeking a highly skilled and experienced Director of Quality Improvement to lead our Quality Improvement Program. This leadership position is responsible for the development, implementation, and oversight of quality assurance and performance improvement activities within the organization.

Key Responsibilities
  • Ensure compliance with all regulatory agencies, including CMS, AHCA, and state-specific guidelines.
  • Oversee the Quality Improvement Department, including training and developing the team.
  • Manage the operations of the Quality of Care / Quality of Service Grievance Department.
  • Identify and follow-up on potential quality/compliance issues.
  • Participate in the Quality Improvement Committee, Appeals and Grievance Committee, and Medical Management Committee.
  • Provide quarterly reports to the Quality Improvement Committee, governmental agencies, and other regulatory agencies as needed.
  • Lead the development of policies and procedures to ensure regulatory compliance, including HIPAA requirements.
  • Develop and monitor corrective action plans required by regulatory agencies.
  • Collaborate with the medical staff, administration, and participate in committees as needed.
Requirements
  • Master's degree in health administration or health care quality management, or BS/BA degree with 10+ years of progressive experience in a managed care organization.
  • 5+ years of supervisory experience with responsibilities for hire, termination, and evaluation of team members' performance.
  • Progressive administrative/operations leadership experience in a managed care environment, particularly with Medicare Advantage Plans and SNPs.
  • Knowledge of CMS rules and regulations related to Medicare Advantage programs.
  • Knowledge of Medicare Advantage operating requirements and processes and compliance expectations.
  • Demonstrated clinical proficiency with healthcare performance measures, including HEDIS, Medicare Stars, Pharmacy Quality Alliance (PQA), and Medicare-specific measures.
  • Knowledge of current and evolving NCQA HEDIS Technical Specifications and other state-specific clinical measures.
  • Previous experience coordinating and overseeing HEDIS medical record review, supplemental data collection, and other activities that support annual HEDIS projects.
  • Experience communicating with regulators, auditors, providers, vendors, executives, and other stakeholders.
  • Previous quality improvement directorial experience.
  • Proven track record of strategic planning and program development.
  • Knowledge of statistical and methodological procedures.
  • Leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.


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