Responsible for the program development, implementation, and management of Quality Management initiatives. Collaborates with Senior Medical Director in overseeing medical policies, medical service delivery, and quality of care for health plan members. Supports provision of high quality, cost-effective clinical care with health care providers. Supports maintenance of marketable, high quality, cost effective provider networks. Coordinates, directs, and manages the activities of the department and the quality management program. Responsible for the analysis of the quality of member care received and for the development of plans and programs to support continuous quality improvement. Establishes strategic plans, policies, and procedures at all levels and with all critical operation departments to ensure quality programs will meet or exceed guidelines or requirements.

Essential Functions and Required Skills
Responsible for the development of business plans and budget, recommending changes and enhancements to services and benefits, and implementing management processes according to organization and department policies and procedures. Responsible for compliance with all regulatory and accreditation standards. Responsible for all QI work plans at a market level that will drive quality and improve health outcomes. Responsible for data collection and analysis of quality interventions and collaborates with business owners to develop work plans and actions to improve member satisfaction and health outcomes. Manages NCQA accreditation process, driving work plans and roadmaps for positive survey results. Responsible for monitoring changes to NCQA standards and executes changes to processes to comply. Collaborates with Senior Medical Director to track and trend Quality of Care concerns for membership. Facilitates the QI Committee structure, coordinates the preparation for CMS and DOH audits, provides quality consultation to other departments, submits and monitors corrective action for practitioners not meeting quality standards.

Required Experience
Bachelors degree; Masters preferred. At least six years of experience working in managed care; extensive knowledge of Quality program implementation and management, Medicare, HEDIS, CAHPS, Pay for Quality, STAR ratings, or similar physician bonus programs, and Delegation Oversight program activities. RN or other clinician with experience as NCQA or URAC accreditation surveyor preferred.

For additional information and/or confidential consideration, please contact:

CONSULTANT: Tricia French, RN, BSN
President & CEO
The French Group