Director, Quality Assurance/Operational Integrity

UPMC•Pittsburgh, PA

About The Position

The UPMC Health Plan is seeking a seasoned leader to serve as Director, Quality Assurance and Operational Integrity. This role is responsible for driving audit readiness, operational excellence, and risk mitigation across the organization. The ideal candidate will possess deep auditing expertise and a proven ability to lead high-performing teams, build strong stakeholder partnerships, and ensure the integrity of processes, procedures, and outcomes enterprise-wide. Responsible to provide leadership, direction, and oversight of activities and administration for the Quality Assurance and Operational Integrity department assigned scope of responsibilities. This includes value creation and the deliverance of excellence, while creating a top performing management team that partners with our Stakeholders to ensure quality outcomes, the integrity of processes, procedures, and operations, audit readiness, as well as risk mitigation across the ISD. In addition to creating and executing strategy and tactics, the incumbent will be responsible to help build and protect the departments brand while forging positive/productive working relationships and collaborations to meet the risk management needs of the organization.

Requirements

Bachelor's Degree in Business Administration, Accounting, or related field required.
8 years health care experience in the Quality Review, Accounting or Auditing field with at least 5 years of that experience in a managerial role required.
Experience with NCQA accreditation for managed care organizations.
Knowledge of and/or experience with regulatory requirements for the delivery of health plan products, including Medicare and Medicaid.
Ability to interact and consult with Senior Level Leadership to achieve department and business unit goals
Ability to develop goals, action plans and contingency plans; identify information resource requirements, organize resources, establish and communicate expectations and manage multiple tasks simultaneously.

Nice To Haves

MA or MBA degree preferred.
CPA, CFE, or CIA certifications preferred.
Knowledge of health insurance information systems functions and continuous monitoring software to be used as tool for meeting QA objectives is preferred

Responsibilities

Maintains a positive work environment for staff with emphasis on the employee work experience & accountability.
Responsible to recruit, develop, and motivate a high caliber management team to meet or exceed departmental and organizational objectives.
Own strategic relationships, stakeholder perception, and cultivating the department's brand.
Interact extensively with internal and external customers to build and maintain positive relationships supporting business goals and objectives; act as departmental liaison.
Lead work groups that encompass multiple functional areas, systems, identified problems and propose solutions for quality assurance, controls, operational integrity, and effective risk management.
Develops a comprehensive risk assessment, which employs a systematic approach to provide assurance of minimal organizational exposure and maximum organizational coverage.
Develop processes for identifying best practices through benchmarking, data gathering and analysis, and for designing appropriate methods and tools for achieving best practice performance for assigned areas of responsibility.
Oversee the compilation of documentation for auditing purposes in accordance with NCQA, Department of Health, CMS and DPW standards for managed care organizations.
Responsible for advanced technical research as it relates to audits/review planning, and compliance with current regulatory and financial reporting requirements.
Effectively assess employee talent and performance; hold employees to a high standard, delivering with the scope of the job description, increasing the value they deliver annually, as well as ensuring continuous training/tools as appropriate.
Identify critical business objectives, develops and operationalizes business plans to support critical objectives.
Ensure maximum productivity and accuracy on all audits and task activity, which effectively provides management with timely, effective, and valuable feedback.
Inform and advise leadership of current trends, issues, problems and activities in functional areas and develops and implements appropriate interventions to facilitate problem resolution and policy making.
Analyze, evaluate, and present information concerning factors, such as business scenarios, production capabilities, and design and development of department workflows.
Must be able to succinctly communicate, deliver presentations, demonstrate value creation, and work delivered.