Director of Quality Health
Role and Responsibility for Quality 1 Mission: Improve Quality of Care
The Director of Quality Health (DQH) is responsible for improving the health, well-being and quality care of our members. The DQH focuses on clinical, medical, health, and regulatory improvements for the company. The DQH monitors, evaluates, assesses and supports the delivery of quality health through education, recommendations, analysis, development of tools, policies and procedures, and reporting. The DQH has specific responsibility for the following:
- Leads and administers the company Medical Management Team and Care Management Team by developing materials to support the teams. Expanding and using a variety of technology related projects to further enhance our delivery of services including working with our affiliated partners;
- Case Management and Care Coordination
- Managing and implementing vendors allowing our internal team to deliver quality case management
- Ensuring the team delivers coordinated care including post discharge for complex medical cases
- Oversight of Pharmacy Benefit Management including supporting the team and the PBM Hotline. Assisting and supporting the development and maintenance of the formulary, contracting with PBM’s, negotiating discounts and rebates, processing and paying prescription drug claims while maintaining or reducing the pharmacy expenditures of the plan and concurrently trying to improving quality health care outcomes.
- Medical Review and Management:
- Supporting the CMO with medical reviews to validate quality care
- Supporting the Chief Medical Officer through oversight of medical management and care management in the areas of:
- Behavioral Health
- Case Management
- Expanding Access
- Creating, developing, and implementing internal standards and criteria including:
- Workflow processes
- Workflow streams
- Monitoring internal systems and processes to ensure compliance with standards and regulations
- Quality Outcomes and Reporting Measures:
- Improving the quality of care
- Improving the quality scores
- The DQH is also responsible for supporting the following functions:
- Credentialing Oversight
- Grievance and Appeals Oversight
The DQH does much more than carry out the mission and services of the department. He or she collaborates with other departments to improve the quality of care and patient experience. This includes careful review and analysis of policies, procedures, protocols and services throughout the departments to identify opportunities to improve the quality of healthcare delivered by the company. When requested, the DQH will support the departments in developing programs to pursue the opportunities identified.
The DQH is also responsible for developing a formal Quality Health Program consistent with national best practices and an Annual Quality Health Work Plan to address any gaps in quality care and promote improvement. The DQH promotes quality health throughout the company consistent with the Quality Improvement Program, supported by evidence based medicine.
Role and Responsibility for Quality 2 Mission: Meeting Standards and Measurements
The DQH is responsible for meeting all HEDIS, STAR and Quality Measurements for the companies and business lines. The DQH ensures that the quality of healthcare services rendered meets or exceeds professionally recognized community standards. The DQH ensures we meet all regulatory requirements, participates in site visit preparation, and passes all regulatory reviews as well as all certifying body reviews such as NCQA, CMS, and AAHC, URAC, EQRO or state agencies. The DQH is responsible for meeting client’s quality measures, to which company has agreed, as prescribed by stakeholders (internal and external) and complies with state, federal laws and accreditation requirements.
- Sets a clear mission, vision and objectives for the department;
- Fosters teamwork and commitment between Quality Health Team, Care Management Team and Medical Management Team and their respective stakeholders;
- Establishes an environment of accountability and continuous quality improvement;
- Improves team and individual performance through coaching, inspiration, management and engaging employees;
- Delegates tasks appropriately, ensures they are understood and the deliverables are clear;
- Provides team leaders with the education, skills and resources to succeed;
- Celebrates the successes, rewards accomplishments and recognizes team contributions.
- Develops and manages the quality health program and develops and implements the annual quality health work plan. Supports the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards;
- Supports the Medical Management Team and Care Management Team to optimize skills, technology and performance resulting in improved outcomes, quality and cost control;
- Establishes professional relationships with all stakeholders to facilitate quality health process internally and externally;
- Supports compliance and appeals and grievances;
- Recommends changes to improve and support quality, improvement of patient satisfaction and managing controlled costs throughout the company, including system changes as necessary;
- Recommends changes to improve reporting;
- Collaborates with outreach coordinators to support clinical quality health initiatives;
- Communicates new state, federal and third party quality regulations/requirements to the team;
- Leads, facilitates, and advises internal quality health programs as directed;
- Facilitates strategic and tactical planning for the quality health programs, including needs assessments, evaluations, root cause analysis, and interventions;
- Actively organizes, facilitates and participates on committees such as: Medical Management, Care Management, Compliance and Quality Health Committees.
- Required: Minimum of Bachelor's Degree in HealthCare, Nursing, Public Health, Health Administration, Behavioral Health or directly related field;
- Master's Degree in the above fields is a plus.
- 4+ years of experience in quality health programs;
- 5+ years of experience in managed care setting;
- 2+ years of management experience in quality health;
- Experience in Behavioral Health environment is also desired;
- Familiarity with Joint Commission, URAC, AAAHC and NCQA standards.
- Knowledge of community, state and federal laws and resources;
- Strong written, interpersonal and verbal communication skills;
- Strong analytical and problem solving skills;
- Ability to present information effectively and efficiently to the team;
- Strong knowledge of healthcare delivery;
- Able to lead/manage others and influence internal and external stakeholders;
- Able to implement process improvements;
- Must have a strong interest in understanding insurance business practices;
- Microsoft Excel, Word, Visio, PowerPoint, Outlook.
Reporting to: President/CEO
Please send your resume and completed application to CHP Human Resources at:
Mail: Consolidated Health Plans, Human Resources, 2077 Roosevelt Avenue, Springfield, MA 01104-3503
Fax: (413) 452-5329 Attn. Human Resources
Phone: (413) 733-4540 ext. 120
For more information contact us at firstname.lastname@example.org or call us at (413) 733-4540 ext. 120