The Quality Director has quality management responsibility for all lines of business including Commercial and Government Segments. The Director leads and oversees the Quality Management Program for the business entity, including Health Promotion, HEDIS, CAHPS, HOS, NCQA accreditation, CMS Star ratings management, and all Quality related programs and projects including those mandated by regulatory and accreditation bodies. The Quality Leader has key accountability for quality performance, including maintenance and improvement activities needed to achieve organizational targets, such as for HEDIS results and achieving 4 STAR or higher ratings from CMS on DHP's Medicare Advantage product. The Director of Quality Management will interface with all DHP department leadership, the provider network, and DMG SSM Health leadership to positively drive overall quality performance.
Essential Job Functions:
Establishes strategic direction and manages staff (direct/ indirect reports) working on quality analytics, reporting, and improvement initiatives. Director ensures clinical intervention staff (indirect resources) activities are aligned to overall quality goals/plans and activities are effectively implemented.
Responsible for development of strategy of provider incentives, pharmacy programs, internal quality campaigns, and vendors related to, or impacting, quality metrics including STARS.
Develops and implements quality improvement plans for HEDIS/STARS with related initiatives/interventions required from continual monitoring of relevant quality measures.
Ensures quality reporting is performed routinely with gap identification and reporting to physicians and clinical outreach teams. Provides management reporting/analytics of Stars and HEDIS results to senior leadership.
Ensures periodic review of DHP approaches to optimize quality results including analytic toolsets, data management, provider contract incentives, product design, and intervention approaches.
Develops provider and member outreach models and/or programming to close quality gaps. For providers, ensure distinct owner/non-owner approaches are developed utilizing provider quality benchmarking and incentives.
Participates in, organizes and leads committees and workgroups to advance quality goals, performance and operations such as Performance Ratings Steering Committee and Quality Improvement Committee. Partners with Provider contracting in development/revisions of risk based or pay for performance programs to support quality management;
Provides subject matter expertise to all departments including Provider contracting related to quality as needed during negotiations and value-based contract development, Sales, Product, and Compliance.
Ensures adequate policy and procedure documentation are maintained for Quality Management activities.
Responsible for NCQA readiness, accreditation, and ongoing compliance with NCQA requirements.
Responsible for achieving all quality management/quality improvement regulatory program requirements; ensures direct and indirect resources are aligned to support regulatory and improvement imperatives.
Provides leadership to providers to achieve star targets. Engages providers to achieve goals. Produces regular tracking reports and monitor progress. Communicate identified gap areas. Facilitate and collaborate with providers to close identified gaps. Build and maintain positive provider relationships.
Serve as primary driver of Quality and Safety Performance Improvement within the health plan and across the network, including committee oversight, work plans and annual evaluation.
Provides leadership and oversight of employer-based health promotion strategy and programming.
Vendor operations management and budget responsibility
Bachelor's degree in relevant field of study with Quality certification, Master's degree, or equivalent experience.
6 years of experience working in health industry.
5 years of quality management leadership experience.
3 years of STAR CMS ratings experience, director level strongly preferred.
Medicare Advantage direct responsibility, extensive knowledge of and experience with NCQA, CMS and Stars, HEDIS, HOS, and CAHPS.
Highly organized with excellent project management skills.
Ability to drive business transformation and work well with senior leadership.
Ability to organize and facilitate multidisciplinary workgroups with a systematic approach toward problems solving. Excellent change management and operational skills.
Proven ability to work autonomously, and build solid teams.
Highly proficient at multi-tasking and prioritization multiple priorities.
Ability to build key stakeholder and partnership relationships.
Master's degree in a work-related discipline/field.
Prior experience with ACA, Commercial and Medicaid products.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same