Role: Director of Quality Improvement/Utilization Management (QI/UM) and Accreditation.

The Director is responsible for developing and coordinating all Quality Improvement Program-related activities, objectives, and analysis including conducting quality improvement studies. The Director of QI/UM provides ongoing development, maintenance and evaluation of quality systems and strategies focused on NCQA PCMH, HEDIS, and CAHPS for all products and services as well as all Utilization Management activities. This position has oversight responsibilities for the quality of provided service delivery and overall performance reviews in clinical risk management/quality and utilization. Establishes annual work plans and program evaluations, policies, and procedures at all levels to ensure quality and utilization programs will meet or exceed guidelines.

Position Responsibilities:

• Responsible for the management and direction of the Quality Improvement/Utilization Management (QI/UM) department and all related activities.
• Establishes quality improvement objectives to meet the demographic and epidemiological needs of the population served and provide high quality and culturally appropriate care.
• Ensures compliance with federal, state, and accreditation standards by developing, implementing and maintaining compliance processes within the department.
• Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.
• Responsible for ensuring compliance and providing direction and guidance on clinical quality improvement and management programs including National Committee for Quality Assurance (NCQA).
• Responsible for the reporting and analyzing of member care quality and for the development of plans and programs to support continuous quality improvement using HEDIS, CAHPS and other tools.
• Responsible for the reporting and analyzation of all utilization management activities.
• Ensures necessary steps are taken to achieve a successful year over year improvement of HEDIS measures.
• Works collaboratively with key health care professionals toward identification of opportunities for improvement, trend analysis, education that result in the development of appropriate action plans for problem resolution.
• Serve as a resource working with research staff in study design, data collection, analysis, and reporting activities that support quality improvement interventions, transparency, compliance regulatory standards, and provider performance monitoring.
• Ensure QI/UM departmental policies and procedures are updated annually, new policies are developed as needed, and that all staff members are appropriately trained in these updates.
• Represents QI/UM department by participating in assigned committees and interdisciplinary workgroups.

Registered Nurse with a Bachelors of Science degree.

• Masters is preferred.
• 5+ years experience in Utilization and Quality Improvement.
• NCQA experience.
• Strong critical thinking skills, communication skills, and documentation skills.
• Statistical ability to analyze data.
• Working knowledge of utilization management/case management/disease management preferred.
• Strong computer skills and experience with Microsoft Office Suites including the development of spreadsheets.
• Must be proficient with NCQA Standards, HEDIS, CAHPS and Star Ratings.
• Leads by influence with the ability to engage and motivate staff toward success and achievement of common goals.
• Strong problem solving and decision making skills.
• An individual who is passionate about playing a key role in changing the current health care insurance landscape.
• Is eager to embrace the challenges and opportunities inherent in a start-up initiative.
• Has the desire and ability to balance a commitment to meeting social needs while achieving financial sustainability of the organization.
• An individual who believes that how we do things is as important as what we do and is interested in rolling up their sleeves, in working collaboratively and cross functionally.