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CNC Director of Quality

Under the general supervision of the Chief Medical Officer, provides strategic direction and hands-on operational management for the Quality programs of the health plan. This includes HEDIS, CAHPS, HOS, QIP/CCIP and any other Quality initiatives. Creates a detailed work-plan to achieve, at minimum, a 4 STAR rating. Responsible for all NCQA and CMS Quality-related activities. Point of Contact with regulatory agencies for Quality. Point of Contact for HEDIS, CAHPS and HOS vendors, and HEDIS auditor.

Principal Responsibilities
• Develops strategy and actionable plan for achieving, at a minimum, a 4 STAR rating for the HMO and PPO, and executing the plan.
• Direct supervision of Quality department and staff.
• Primary Subject Matter Expert for Quality.
• Direct accountability for HEDIS file audit and submission processes.
• Works closely with the executive team and reports weekly.
• Responsible for Quality-related vendor supervision.
• Develops and maintains documentation consistent with NCQA and CMS regulations, company goals and policies.
• Remains up to date on all changes to HEDIS measures and NCQA and CMS programmatic requirements and educates leadership.
• Supervision of administrative, hybrid and supplemental compliance data acquisition and management.
• Works closely with the Business Intelligence team and Health Care Data Analyst to maintain integrity of Quality data.
• Ongoing and year-end Quality data and results analysis, including necessary corrective actions

Position Responsibilities
• Minimum of three years’ experience at a Management level in Quality working with Medicare Advantage plans.
• 5 years’ experience managing people.
• Deep knowledge of HEDIS technical specifications and NCQA and CMS Quality programs.

Educational Requirements
• Requires a Bachelor’s Degree and 5 years’ experience

Skills or Special Abilities:
• Ability to handle ambiguity.
• Ability to think strategically and develop initiatives and processes to achieve stated goals.
• Excellent problem solving, communication, and organizational skills
• Ability to motivate team and hold team accountable for the results
• Ability to handle multiple projects and heavy workloads
• Ability to work independently or as a team
• Deep knowledge of Quality file transfer and audit processes.
• Proficient in Microsoft Office (Excel, Word, PowerPoint)

Physical Requirements:

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands:
• Must be able to frequently sit, use finger dexterity, has good vision, hearing, and speaking to promote information exchange.
• Must be able to stand and use a copier, collate, staple, and bind large packets for meetings.
• Occasionally may have to lift boxes of office supplies and stack reams of paper on high shelves.

Mental Demands:
• Must be able to frequently problem solve, make decisions, interpret data, organize and analyze work flow, write, plan, and use simple arithmetic.

Working Conditions:
• Work is conducted indoors.
• Requires sitting at a desk in an office settings.
• Position requires driving personal vehicle and interfacing with medical office personnel.

Major activities of the job include:
• Must be able to operate general office equipment including but not limited to: computer, phones, and related media and information devices.

Communication requirement:
• Must have the ability to communicate in writing, speaking, and hearing, both in person and/or by telephone.

The above job description is not intended to be an exhaustive list of all responsibilities, duties, and skills required of the job. Management retains the right to add or to change the duties of the positions at any time with or without notice.

Time:  Full time
Salary:  Salary
Category:  Clinical/pharmacy/quality

Updated: 3/12/2019 6:16:48 PM