Director of Clinical Quality / 13-4294 at Medford

Position Description:

The Director of Quality Management conducts program management activities and strengthens infrastructure for Network Health’s Quality Department. Quality Management responsibilities include, but are not limited to: HEDIS, CAHPS, NCQA, QIP, and EQRO activities. Additionally the Director of Quality is responsible for leading the quality improvement committee and the quality concerns committee and participating in the Quality Management Committee, the Utilization Management Committee, the Clinical Quality Steering Committee, the Behavioral Health Quality Improvement Committee, the Medical Management Quality Improvement Committee and the Appeals Committee. The Director participates in budget activities and quality improvement efforts.
The director ensures coordination of quality improvement initiatives and activities with clinical and other departments to ensure an integrated approach to effectively improve the quality of services for members and provider partners of Network Health.
The director of Quality is responsible for ensuring that Network Health complies with NCQA requirements, contractual quality requirements, and regulatory quality requirements and utilizes continuous quality improvement principals in all improvement initiatives. In this role the director represents Network Health in quality meetings with Mass Health, the Connector Authority, and with the Executive Office of Health and Human Services (EOHHS)) on developing joint MCO policies and procedures and communicating changes in policies. The director participates in provider meetings as appropriate.
The director provides oversight, development, implementation and maintenance of quality programs according to federal requirements, state requirements and/or initiatives, NCQA accreditation requirements, and Network Health goals.

The Director of Quality promotes the mission and values of the Clinical Affairs Department, Network Health, and Tufts Health Plan.

• Oversee the selection of Network Health’s annual HEDIS measures. Ensure that the HEDIS reporting process is accurate, effective, efficient, and able to meet all contractual obligations and related timelines.
• Manage Network Health’s HEDIS and CAHPS quality improvement plans, initiatives, and activities.
• Oversee Network Health's participation in MassHealth’s External Quality Review and Quality Improvement Program activities including meeting all plan and other contractual requirements on quality program initiatives and objectives, including meeting QIP and EQRO goals and timelines.
• Participate in MassHealth and other regulatory plan committees and sub-committees as required.
• Serve as the plan's Quality Officer with duties including overseeing the process for the annual development of Network Health’s plan-wide improvement plan; monitoring progress of improvement projects; developing and directing selected improvement projects as deemed necessary and appropriate.  Complete annual evaluation of Quality Improvement activities and provides recommended annual Quality Program structure and Work Plan.
• Ensure that Network Health is in compliance with all annual and other contractual quality improvement goals and objectives and performance review requirements.
• Provide quality leadership, and project management as needed, to Network Health’s on-going efforts to improve the quality of services and operations, including, but not limited to the areas of Medical Management Programs, Behavioral Health Programs, Pharmacy Management Programs, Customer Service Programs, Provider Partner Programs and Operations.
• Serve as key contact for plan on contractual issues as they specifically relate to Quality Management, such as QIP goals, work plans, and committees, HEDIS efforts, CAHPS efforts and External Quality Review.  Provides timely feedback to MassHealth and The Connector as requested.
• Oversee the preparation for Department of Insurance Accreditation as well as NCQA accreditation, as appropriate.
• Represent, or ensure that Network Health is represented, at applicable meetings and activities including but not limited to New England HEDIS Coalition; MassHealth Quality Partnership; MassHealth workgroups.
• Maintain professional growth and development through self-directed learning activities and involvement in professional, civic, and community organizations and/or activities.
• Serve as a quality resource for internal staff and provider sites as needed/requested.
• Perform additional duties as requested.
  

Qualifications:

• Bachelors degree in Business, Public Health, or Human Services required. MBA, MPH, or related field preferred.
• Minimum of 7 years of health care experience, preferably in a health plan environment required.
• Quality Management experience required.
• Experience with program design and evaluation methods required.
• CPHQ (Certified Professional in Healthcare Quality), Six Sigma, Lean Six Sigma preferred.
  

Country: USA, State: Massachusetts, City: Medford, Company: Network Health.