Director Quality Management

Amerihealth Caritas • Tinicum Township, PA

3d • Remote

About The Position

The Director Quality Management is responsible and accountable for the successful, ongoing development, refinement, implementation, measurement, quality improvement, and effectiveness of Long Term Services & Support (LTSS) in Pennsylvania. The position oversees quality management for LTSS and maintains the Plan’s compliance with state regulations, NCQA, URAC, and other applicable standards for Quality, Care Management, and Utilization Management activities. The role also oversees credentialing and re-credentialing, delegation, quality-of-care investigations, committee structures, and related coordination, communication, and education.

Working directly with Senior Executives and Plan stakeholders, the Director plans and leads strategic projects and strategies intended to improve financial, service, and clinical outcomes, improve HEDIS outcomes, maximize pay-for-performance payouts, and reduce withholds or liquidated damages. The role provides functional support across Network Management, Informatics, Information Solutions, Care Coordination, Utilization Management, and Public Affairs to integrate quality initiatives and goals with organizational programs.

This is a fully remote position, and the Associate must reside in Pennsylvania. Travel to state and leadership meetings is required as needed. Reliable high-speed internet is required, with a minimum of 50 Mbps download and 5 Mbps upload. Associates residing in states where reimbursement is required by contract, law, or regulation may submit eligible expenses for reimbursement.

Requirements

• Bachelor’s degree required.
• An active, unrestricted Pennsylvania Registered Nurse (RN) license or a healthcare quality certification such as ABQAURP or CPHQ, in accordance with state-specific requirements.
• 1 to 3 years of experience in Medicaid.
• 5 to 10 years of experience in a clinical setting.
• 5 or more years of experience in managed care and leadership.
• Prior URAC or NCQA accreditation experience.
• Strong leadership and people-management skills.
• Extensive knowledge of healthcare quality assurance, quality improvement, outcomes management, and performance-improvement principles and practices.
• Strong project and program management skills.
• Excellent verbal and written communication skills.
• Strong presentation and facilitation skills.
• Demonstrated problem-solving, critical-thinking, and independent decision-making skills.
• Strong interpersonal and conflict-resolution skills, and ability to collaborate across departments.
• Strong organizational and time-management skills with excellent attention to detail.
• Proficiency with Microsoft Office applications and ability to use technology for reporting, data analysis, documentation, and communication.
• Must reside in Pennsylvania.
• Reliable high-speed internet with at least 50 Mbps download and 5 Mbps upload.

Responsibilities

• Oversee quality management for Long Term Services and Supports (LTSS) in Pennsylvania.
• Maintain the Plan’s compliance with state regulations, NCQA, URAC, and other appropriate standards for Quality, Care Management, and Utilization Management activities.
• Oversee credentialing and re-credentialing, delegation, quality-of-care investigations, and related inter- and intra-departmental coordination, communication, and education.
• Oversee and support the Plan’s, Line of Business’s, or Product Line’s QAPIC Committee structure.
• Work directly with Senior Executives to plan, organize, and direct strategic projects that improve financial, service, and clinical outcomes.
• In coordination with Plan stakeholders, develop, implement, and lead strategies to improve HEDIS outcomes, maximize pay-for-performance payouts, and reduce withholds or liquidated damages.
• Provide functional support to Network Management, Informatics, Information Solutions, Care Coordination, Utilization Management, and Public Affairs to integrate Quality Management initiatives and goals with organizational programs.
• Supervise, coach, develop, and provide performance feedback to quality management staff.
• Develop and present quality reports, analyses, recommendations, and performance findings to leadership and cross-functional stakeholders.
• Manage multiple quality initiatives, priorities, deadlines, and contractual deliverables.
• Identify process-improvement opportunities and lead the development and implementation of improved clinical and administrative processes.

Benefits

• Eligible expenses may be submitted for reimbursement for Associates residing in states where reimbursement is required by contract, law, or regulation.

What This Job Offers

• Job Type: Full-time
• Career Level: Director