Quality Improvement Lead

Profile

Description

Responsibilities

The Quality Improvement Lead provides strategic leadership for Humana's South Carolina Medicaid Quality Program, in alignment with organizational quality and population health goals and ensuring compliance with all contract, state, and federal requirements. They will support NCQA accreditation and will serve as the local market lead for accreditation compliance. The Lead has oversight of quality investigations and compliance processes, including evaluating and investigations into quality of care concerns. This position has primary responsibility to operate a quality management infrastructure which promotes member safety, quality of care, improves health disparities, is culturally competent and assures cost effective access to care in the safest, least restrictive setting. This role requires commitment to cross-functional collaboration to drive continuous quality improvement throughout health plan operations, provider network and community partnerships to achieve our quality improvement goals and objectives.

Position Responsibilities:


Operate an NCQA compliant quality program
Oversee the development, implementation and management of quality improvement projects and work collaboratively to address health equity and social determinants of health
Partner with Population Health Director to inform population health strategy and target improvement areas including the design of clinical programs that improve health outcomes and reduce health disparities
Oversee HEDIS, CAHPS, and other required measure reporting and evaluation
Ensure compliance with quality of care investigations and reporting
Provide oversight of the Annual Quality Program Description, Annual Quality Work Plan, and the Annual Quality Program Evaluation
Improve quality measure performance through innovative approaches in engaging members and providers
Analyze dashboards consisting of Key Performance Indicators (KPI), and non-KPI metrics, interpreting trends and significant variances as opportunities to improve outcomes
Incorporate actionable analytics, utilizing business intelligence tools, care coordination tools, and claims systems to identify issues, mitigate risks, and develop and execute solutions
Serve on standing committees of governance and quality management
Responsible for maintaining confidential information in accordance with policies, and state and federal laws, rules and regulations regarding confidentiality


Required Qualifications


Bachelor's degree in nursing, public health, health administration, health policy or business; Master's degree preferred
Minimum five years of experience in Quality Improvement/Quality Assurance for a managed care organization
Minimum five years of experience in management and supervision
Clinical program development and implementation experience
Strong understanding of NCQA Health Plan accreditation standards and requirements
Demonstrated skills in quality improvement concepts, health care data analysis, data mining methods and the identification of population health issues, trends, and health disparities using health care data sources
Understanding of value based payment models that reward quality improvement
Understanding of cultural factors that influence health outcomes and implementing culturally competent improvement interventions
Experience implementing rapid-cycle improvement techniques that demonstrated material improvements
Excellent communication skills and experience in cross-functional collaboration in matrixed organizations
Ability to travel locally/regionally throughout SC
Must reside in SC
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.


Preferred Qualifications


Registered Nurse or equivalent clinical licensure strongly preferred
CPHQ preferred / CPHQM Preferred


Scheduled Weekly Hours

40

Company info

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