Sr. Director, Quality & Population Health(Must Live In Indiana)

CareSource • Indianapolis, IN

6d

About The Position

Job Summary: The Senior Director, Quality Improvement and Population Health is responsible for executing Quality and Population Health Strategies to achieve defined quality goals and outcomes for product or market. Essential Functions: Execute Quality Strategy and Population Health Strategy to achieve goals and outcomes for product or market Lead and collaborate with internal and external stakeholders to drive quality initiatives. Effectively represent CareSource with regulators and auditors to ensure continuous contract compliance as well as demonstrable innovation in quality program administration. Oversee population health management documentation and timely submission Ensure effective application of population health management model is conducted through the lens of health equity, including rigorous approach to population assessment, program measurement and evaluation Assist in determination of benchmarks, goals and outcomes for defined programs, informed by analytics and evidenced based practice. Serve as key liaison to state and/or federal health care program agencies regarding quality improvement and population health activities Participate in national health standards committees and focus groups specific to specialty programming and interventions, providing input on behalf of CareSource Provide oversight of programmatic and interventional activities in accordance with contractual, regulatory requirements and NCQA standards Support care management programs as necessary utilizing NCQA standards to sustain accreditation if applicable Monitor compliance within product and/or market to promote standardization while ensuring compliance with provider agreement requirements Collaborate with Physician Relations, Medical Director, Community Marketing and Corporate/BPG to deliver market outcomes Develop and sustain community service agency relationships and provide general quality oversight for contracted community partner services Ensure quality requirements are met through continual review, audit and monitoring of quality improvement/performance improvement activities, including case management quality, HEDIS and STARS performance Co-Chair Ohio Quality Improvement Committee. Provide leadership support for Population Health and Health Equity workgroups. Direct, participate and drive the prioritization of product/program projects ensuring alignment with organization wide initiatives Work closely with the information technology (IT) to ensure innovative technological advancements, including clinical and health risk assessments care planning, reporting, trending, tools, etc. are used daily to improve member care, quality and outcomes Work closely with the Provider Relations team to ensure that the product/ programs have specialized network expertise which utilizes appropriate clinical practice guidelines and protocols Collaborate with Enterprise team to identify, deliver and oversee relevant education and training Collaborate with CareSource Internal Audit and Regulatory Departments in ensuring compliance with all regulatory requirements Ensure compliance with the MOC and oversee model of care for product Ensure compliance with all statutes and regulations for product Develop and maintain an in-depth knowledge of the company’s business and regulatory environments Direct, manage, and oversee the work of the market quality / operations team Maintain, develop and implement care management policies, procedures, goals and utilization protocols; design and improve the product to improve the quality of care and lower total cost of care for members Review and provide input to the member benefit package at designated intervals Perform any other job duties as requested

Requirements

• Bachelor’s Degree in health care field or equivalent years of relevant work experience is required
• Minimum of five (5) years of healthcare, healthcare operations and/or managed care experience with managed care performance metrics and HMO concepts is required
• Minimum of five (5) years of experience in case management, disease management, medical management, and/or quality improvement required
• Minimum of five (5) years of leadership/management experience is required
• Proficient in Microsoft Excel, Word, PowerPoint and Excel
• Knowledge of regulatory reporting and compliance requirements both Medicaid and Medicare
• Knowledge of managed care industry and its trends
• Knowledge of clinical guidelines (Milliman, InterQual)
• Advanced knowledge of HEDIS and STAR performance metrics
• Critical listening and systematic thinking skills
• Ability to maintain confidentiality and act in the company’s best interest
• Strong oral, written, and interpersonal communication skills
• Excellent leadership, management and supervisory skills and experience
• Energetic, enthusiastic, and politically astute
• Ability to act with diplomacy and sensitivity to cultural diversity
• Responsive to a changing environment
• Strategic management skills
• Conflict resolution skills
• Planning, problem identification and resolution skills
• Business process/management skills
• Current, unrestricted license as a Registered Nurse (RN) in state of practice is required or Certified Professional in Health Care Quality (CPHQ) by the National Association for Healthcare Quality (NAHQ), Certified Quality Improvement Associate (CQIA) by the American Society for Quality (ASQ), and/or Certified in Health Care Quality Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers (ABQAURP) within six (6) months of employment is required

Nice To Haves

• Master’s degree in health-related field is preferred
• Three to five (3-5) years of Government program experience is preferred

Responsibilities

• Execute Quality Strategy and Population Health Strategy to achieve goals and outcomes for product or market
• Lead and collaborate with internal and external stakeholders to drive quality initiatives.
• Effectively represent CareSource with regulators and auditors to ensure continuous contract compliance as well as demonstrable innovation in quality program administration.
• Oversee population health management documentation and timely submission
• Ensure effective application of population health management model is conducted through the lens of health equity, including rigorous approach to population assessment, program measurement and evaluation
• Assist in determination of benchmarks, goals and outcomes for defined programs, informed by analytics and evidenced based practice.
• Serve as key liaison to state and/or federal health care program agencies regarding quality improvement and population health activities
• Participate in national health standards committees and focus groups specific to specialty programming and interventions, providing input on behalf of CareSource
• Provide oversight of programmatic and interventional activities in accordance with contractual, regulatory requirements and NCQA standards
• Support care management programs as necessary utilizing NCQA standards to sustain accreditation if applicable
• Monitor compliance within product and/or market to promote standardization while ensuring compliance with provider agreement requirements
• Collaborate with Physician Relations, Medical Director, Community Marketing and Corporate/BPG to deliver market outcomes
• Develop and sustain community service agency relationships and provide general quality oversight for contracted community partner services
• Ensure quality requirements are met through continual review, audit and monitoring of quality improvement/performance improvement activities, including case management quality, HEDIS and STARS performance
• Co-Chair Ohio Quality Improvement Committee.
• Provide leadership support for Population Health and Health Equity workgroups.
• Direct, participate and drive the prioritization of product/program projects ensuring alignment with organization wide initiatives
• Work closely with the information technology (IT) to ensure innovative technological advancements, including clinical and health risk assessments care planning, reporting, trending, tools, etc. are used daily to improve member care, quality and outcomes
• Work closely with the Provider Relations team to ensure that the product/ programs have specialized network expertise which utilizes appropriate clinical practice guidelines and protocols
• Collaborate with Enterprise team to identify, deliver and oversee relevant education and training
• Collaborate with CareSource Internal Audit and Regulatory Departments in ensuring compliance with all regulatory requirements
• Ensure compliance with the MOC and oversee model of care for product
• Ensure compliance with all statutes and regulations for product
• Develop and maintain an in-depth knowledge of the company’s business and regulatory environments
• Direct, manage, and oversee the work of the market quality / operations team
• Maintain, develop and implement care management policies, procedures, goals and utilization protocols; design and improve the product to improve the quality of care and lower total cost of care for members
• Review and provide input to the member benefit package at designated intervals
• Perform any other job duties as requested

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level