Health Plan Quality & Performance Improvement Director

  • Oversees the operation of multiple units within a department; ensures the management of work assignment completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Gains cross-functional support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and fosters resolution of escalated issues. Communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; prioritizes and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; ensures teams accomplish business objectives.
  • Directs data collection and analyses to support quality improvement reporting by: overseeing statistical analysis for quality improvement evaluations, special projects, and other work for multidisciplinary review; defining the standards for integrating multiple utilization data reporting systems to develop and maintain a variety of statistical reports in a format which enables care providers to see variations in practice patterns that are adaptable/customizable to adheres to specified formats; presenting and advising on the application of quality improvement metric reports to demonstrate improvements and effectiveness of quality improvement programs to a variety of technical and nontechnical audiences at the senior and executive management level to ensure continued growth and success at KP; and serving as a technical expert to senior and executive management by interpreting and implementing strategies to improve data collection, reporting, and analysis at the organizational level and advising on integration into business goals/objectives to improve KP capability.
  • Directs quality improvement and improvement risk management efforts by: defining the standards for corrective action plan for improvement identified through utilization review, clinical records audit, claim denials, member satisfaction surveys, and auditing surveys across the organization; ensuring current and future process improvements are compliant with established internal and external regulation requirements at the regional and federal level; defining the standards for root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches; and defining the standards for escalating high-risk issues and trends.
  • Establishes the standards and integration of quality improvement performance metrics development, collection, and utilization at the regional and organizational level by: consulting with senior and executive management in setting the standards for performance metrics, standards, and methods to establish improvement success; consulting with senior stakeholders, often with competing/conflicting objectives, to ensure development of cohesive and reachable metrics are practical, meet multidisciplinary standards, and are in line with KP goals; and monitoring the delivery of measurable results and alignment with strategic objectives by integrating metric utilization into workflows, and providing expertise in the development of project structure, charters, metrics, and work agreements throughout the project lifecycle.
  • Oversees the development and standards of KP-wide quality improvement initiatives by: directing the implementation of new technology, methods, and tools to develop stakeholders capabilities for process improvements into practice; serving as the technical advisor to senior management on data-driven improvement principles, tools, and problem-solving methods, including Lean/Six-Sigma concepts and techniques using quality improvement metrics; synthesizing key information, breaking down issues into logical components, and identifying barriers to overcome when creating milestones, detailed workplans, and documentation practices in order to create a clear, and realistic plan for regional level improvement processes; and consulting with regional internal and external stakeholders, to define the strategies for quality improvement processes to have consistent design and application of improvement methodologies, use of technology, and prioritization of quality improvement initiatives.
  • Serves as the subject matter expert for quality improvement processes and regulations for region, internal and external committees, and key stakeholders by: providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation and advises on the current climate and potential changes which may have long term effects on business operations; proactively engaging internal and external committees, projects, and relevant initiatives to implement change and to move QA initiatives forward; maintaining collaborative, results oriented partnerships to ensure current and future compliance and advises on changes to KP policy; defining the standards for educational programs to raise awareness for current and changes in regulation requirement, internal concerns, and system/database usage; and identifying systematic barriers to process improvements issues and weighs practical, technical, and KP capability considerations in addressing issues and advises on policy changes.

Minimum Qualifications:

  • Minimum two (2) years of experience managing operational or project budgets.
  • Minimum five (5) years of experience in a leadership role with direct reports.
  • Minimum two (2) years of experience with databases and spreadsheets or continuous quality improvement (CQI) tools.
  • Minimum seven (7) years of experience in clinical setting, health care administration, or a directly related field.
  • Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum eight (8) years of experience in heath care quality assurance/improvement or directly related field OR Minimum eleven (11) years of experience in heath care quality assurance/improvement or a directly related field.
  • Professional Healthcare Quality Certificate within 24 months of hire OR Professional in Healthcare Risk Management Certificate within 24 months.

Preferred Qualifications:

  • Master’s degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field.
  • RN or BSN

Location: Atlanta, Georgia

Full time: Yes

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