Director, Quality & Risk Adjustment (Utah Health Plan) - REMOTE

Molina Healthcare•Long Beach, CA

13h•Remote

About The Position

The Director, Quality & Risk Adjustment is responsible for leading health plan execution for Risk and Quality ensuring alignment of strategy and activities with Enterprise and acting as the Risk and Quality subject matter expert for the health plan. Primary interface with state agencies, leadership of local Quality committees and oversight and execution of local intervention activities intended to improve quality measures and outcomes. Collaborates with MHI Quality leaders to conduct data collection, reporting and monitoring for key Quality performance measurement activities. Coordinates with MHI Quality leaders on the implementation of NCQA accreditation surveys and federal QI compliance activities. Responsible for local execution supporting Medicare Stars strategies and performance improvement.

Requirements

Bachelor's Degree in a related field (Healthcare Administration, Public Health, or equivalent experience.
Minimum 8 years experience in quality compliance/HEDIS operations, customer service or provider service in a managed care setting with previous leadership experience to include managing people, project management, team building, and experience developing performance measures that support business objectives.
Possesses a strong knowledge in risk and quality in order to implement effective interventions that drive change.
Ability to inspire and work directly with external providers to advance Molina’s Value-based quality initiatives.
Ability to collaborate and educate network providers to develop effective practice-based quality improvements.
Deep knowledge of Quality Discipline including metrics and performance standards. Working knowledge of Risk Adjustment.
Project management experience, in a managed healthcare setting.

Nice To Haves

8+ years experience in managed healthcare administration.
8+ years experience in Quality leadership role with a Managed Care Payer with experience in all lines of business.
3-5 years of Risk Adjustment experience.

Responsibilities

Serves as the primary contact to State agencies for all Risk and Quality matters.
Leads the local Quality committees.
Prepares, in collaboration and support with MHI Quality, required documentation for state Performance Improvement Projects.
Aligns with Enterprise the design, implementation, and monitoring the effectiveness of a comprehensive Risk and Quality intervention strategy, acting as a critical stakeholder in establishing the strategic direction from the interventions Joint Operations Committee.
Collaborates with the MHI RQES teams for Risk and Quality Interventions supporting analytics and strategic teams to develop, present and evaluate intervention strategies.
Collaborates with MHI Quality for accreditation activities.
Key stakeholder to MHI RQES for planning and implementing evidence-based quality intervention strategies and initiatives that meet state and federal intervention rules and are aligned with effective practices as identified in the healthcare quality improvement literature and within Molina strategic plans.
Serves as operations and implementation lead for local execution of Molina plan quality improvement activities using a defined roadmap, timeline and key performance indicators for Risk and Quality.
Communicates with leadership about key deliverables, timelines, barriers and escalated issues that need immediate attention.
Partners with MHI RQES and Plan Network leadership to support establishing QI benchmarks and requirements for VBC contracts.
Responsible for partnering with MHI RQES and VP Stars in developing the local Medicare Stars work plan and executing on interventions that will improve CAHPS, HEDIS and HOS scores. Responsible for monitoring Part D and Operational health insurance metrics and coordinating with centralized teams to improve these metrics.
Responsible for partnering with MHI RQES and VP Stars in managing MMP quality withhold revenue in MMP States. Support development of interventions and a local strategy to improve withhold revenue earned to meet or exceed budgeted goals.
Collaborates with MHI risk and quality analytics for broad-based quality data analytics.
Oversees Health Plan local resources to facilitate local clinical data acquisition for abstraction for required VBC customized reports to meet VBC network contract obligations not supported by the national MHI team.
Presents summaries, key takeaways and action steps about Molina risk and quality strategy to national, regional and plan meetings. Lead and influence cross-functional teams that oversee implementation of risk and quality interventions. Functions as local leader for intervention execution partnering with MHI RQES for qualitative and quantitative analysis, expected ROI analysis, key performance indicator development, reporting and development of program materials, templates or policies.
Member of the State’s Provider Engagement team for large, contracted, value-based provider systems.
Attends state and regional Quality Improvement and/or Board of Directors Meetings and represent the Health Plan.