VP Quality Health Plan

Presbyterian Healthcare Services

2d•Remote

About The Position

The Vice President of Quality provides leadership for all activities relating to the development and management of the Plan’s quality improvement and accreditation activities including NCQA, contractual and regulatory quality requirements and measures for all lines of business including but not limited to HEDIS/Performance Improvement, clinical quality programs, clinical vendor management (excluding Pharmacy Benefit Manager). This role also develops and oversees strategies, policies and processes to ensure implementation of programmatic initiatives related to these areas with both internal and external stakeholders.

Requirements

Bachelor’s degree in Health Care Administration, Public Health, Nursing, or related field or the equivalent combination of training and experience is required.
Active clinical licensure required.
10+ years progressively responsible experience in leading Quality Improvement Programs, which includes supervision of staff and budget management, is required.
Comprehensive knowledge of Medicaid regulations, guidelines and standards is required.
Comprehensive knowledge of accreditation organizations such as NCQA is required.

Nice To Haves

Master’s degree in related field strongly preferred.
Active clinical licensure as a Registered Nurse strongly preferred.
CPHQ certification strongly preferred.
Experience within a managed care organization is strongly preferred.
Previous experience in designing and leading an accreditation process is strongly preferred.

Responsibilities

Responsible for executing on operational strategies and programs using complex analytics and reporting to support Medicare Star Ratings, HEDIS, and Quality Intervention Programs.
Responsible for the annual HEDIS submission, PHP Medicare Star Program Ratings, NCQA accreditation, and regulatory and contractual compliance.
Directs the activities for Performance Improvement intervention programs, HEDIS/Star analytics and reporting and abstraction activities.
Designs, implements and leads the Plan’s continuous quality improvement infrastructure.
Acts as an internal consultant and resource to all levels of the organization relative to CQI processes and standards.
Works in collaboration with the broader PHS system to identify opportunities, implement innovations and evaluate outcomes
Oversees the development and execution of Stars strategy in conjunction with key business partners
Responsible the development and execution of the organizations Medicare and Medicaid Sustainability and strategy in determining an approach to securing and maintaining an annual Medicare Advantage Star Rating of 4.0 or higher, meeting 100% of Medicaid Performance Measure targets, and ensuring the maintenance of NCQA health plan accreditation for all lines of business.
Leads all Plan activities for National Committee for Quality Assurance (NCQA) re-accreditation.
Responsible for the ongoing administrative, clinical, fiscal and programmatic interaction with NCQA.
Communicates with NCQA as needed to ensure the Plan is informed of all events and circumstances that affect the initial and on-going achievement of NCQA accreditation.
Is responsible for overall Utilization Program Compliance as it pertains to accreditation obligations.
Oversees quality of care studies (based on targeted areas for quality management and quality improvement). This includes the following: analyzes data, performs root cause analysis, facilitates plans for improvement, provides technical support to Plan managers, and conducts re-measurement activities to assess performance improvement.
Monitors quality performance indicators; prepares reports for quality oversight committees; develops vehicles to communicate performance to providers; and identifies clinical and administrative concerns for further investigation and analysis.
Develops and manages communications with providers, government and accreditation organizations with respect to results of quality management studies, including oversight of remedial action as required.
Directs the supervision of subordinate staff to include hiring, work allocation, scheduling, training and professional development, problem resolution, performance evaluation and related supervisory activities.
Maintains budgetary responsibility for responsible departments.