Responsibilities:

The primary purpose of the job is to be responsible and accountable for the successful, ongoing development, refinement, implementation, measurement, ongoing quality improvement and effectiveness of the Health Plan’s, Line of Business or Product’s Quality Management Program. With consideration of state contract requirements, the Quality Director may be responsible for overseeing multiple lines of business (i.e. Medicaid, Medicare, Long Term Services and Supports, and Medicare-Medicaid Plans) within a state. Additionally, the position is responsible and accountable for ongoing maintenance of the Plan’s compliance with state regulations and NCQA/URAC and other appropriate standards for activities related to Quality, Care Management and Utilization Management. This includes credentialing/re-credentialing activity, delegation oversight, quality of care investigations as well as the corresponding inter- and intra-departmental coordination, communication, and education. The Director of Quality Management provides primary oversight and responsibility for the Plan’s, Line of Business or Product Line’s QAPIC Committee structure and support.

• Works directly with Senior Executives to plan, organize and direct the identification, prioritization and implementation of strategic projects that improve financial, service and clinical outcomes for the Plan, LOB or Product Line.
• In coordination with Plan stakeholders, develop, implement and lead strategy to improve HEDIS outcomes and maximize pay for performance payout and reduce withholds and/or liquidated damages
• Provides functional support to the Network Management, Informatics, Information Solutions, Care Coordination, Utilization Management, and Public Affairs departments to integrate Quality Management initiatives and goals with organizational programs. 

The Quality Director plays an active role in the dissemination of the Quality Management best practices throughout the AmeriHealth Caritas Family of Companies and assists with new business opportunities and implementation. 

Education/ Experience: 

• Bachelor’s Degree.
• Current state RN license or Health care quality certification (i.e. ABQAURP or CPHQ) in accordance with state specific requirements.
• Valid driver’s license required.
• 1-2 years working with Medicaid/Medicare and STAR programs.
• 5-10 years in clinical areas.
• 5 years managed care experience.
• 5 year’s managerial experience.
• Prior URAC or NCQA Accreditation experience.
• An unrestricted nursing license to practice nursing in the plan’s state or any other state he/she works. RN license may be required based on market needs and/or contractual requirements.
• Prefer experience supporting multiple health plans, preferably at the regional or corporate level.