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NURSE JOB SUMMARY:
The Director of Quality Management is responsible in conjunction with the plan QM leader, the Plan Medical Director and CEO for developing, coordinating, and implementing quality initiatives within the health plan; to include indicators for monitoring and evaluation of quality of care/service, appropriateness, continuous improvement, member satisfaction, and results of actions across the continuum of care to members. Coordinates the quality management program activities throughout the functional areas of the health plan and provides education in the area of quality management. Collaborates with the state and federal regulatory agencies on quality initiatives and provides leadership in the accreditation efforts for the health plan in conjunction with the Medical Director and Health Plan Management.

PRIMARY RESPONSIBILITIES:

  • Establishes QM objectives and annual goals in conjunction with the Medical Director.
  • Directs implementation of the comprehensive Quality Management Program to meet the demographic and epidemiological needs of the population served.
  • Promotes plan-wide understanding, communication, and coordination of the quality management program.
  • Trends quality data and develops aggregate and individual plan reports as indicated.
  • Develops quality management reports.
  • Analyzes validity of quality management data/reports from a clinical perspective.
  • Coordinates on a quarterly basis reporting of all quality initiatives to all appropriate committees.
  • Develops, designs, implements and evaluates quality improvement activities including coordination of the quality focus studies and other indicators of quality of care/service.
  • Coordinates development, implementation, and evaluation of continuous quality improvement action plans for the quality improvement activities.
  • Coordinates the activities of the peer review process.
  • Participates in the reporting of the Health Employer Data Information Sets (HEDIS) data and coordinates the improvement action plans.
  • Coordinates the state regulatory quality reporting for the health plan.
  • Provides Plan leadership to meet National Committee for Quality Assurance (NCQA) standards.
  • Provides support for provider re-credentialing in the areas of medical record reviews and quality indicators.
  • Assures compliance with State and Federal quality improvement/assurance requirements.
  • Evaluates and makes recommendations for oversight of delegated services.
  • Develops the annual operating and capital budgets to sufficiently meet departmental needs and ensures that department stays within budget and accounts for variances.
  • Interviews, manages, evaluates, and develops new and existing departmental staff.
  • Demonstrates skill in facilitating groups including CQI facilitation.
  • Set goals, establishes measurements, quality standards and tracking mechanisms.
  • Anticipates and works with plan and corporate team to prioritize work requirements, balance competing priorities for resources, and develop plans to address those needs having the greatest impact.
  • Other Duties as Assigned

Job Requirements
EDUCATION AND EXPERIENCE:
Education
Required:    Bachelor Degree required
Preferred:    MSN, MPH, MPA  preferred

Years and Type of Experience
Required:   Minimum of seven years of current progressive experience in quality improvement in a managed care organization and at least 3 years management/leadership experience.
Preferred:

  • Previous NCQA accreditation and HEDIS reporting experience preferred
  • Experience with the urban Medicaid population preferred

Certifications or Licensure
Required:     Registered Nurse licensed in health plan state
Preferred:    CPHQ preferred.

Abe Ghebrehiwet Senior Account Executive Nurse Resolutions
888.411.2228. Toll Free 407.341.9647. Cell 407.982.7508. Fax
www.NurseResolutions.com

Filed under : nurse, registered nurse,