PURPOSE OF POSITION:

The Director of Clinical Quality, Disease Management and Case Management reports to the Vice President of Quality and works closely within the Quality team and in collaboration with other operational and clinical teams in order to administer the organizations Quality program and workplan in order to meet all quality of care and quality of service goals of the organization.

The primary purpose of the Director Clinical Quality, Disease Management and Case Management is to provide strategic recommendations, design and execution of those strategies and initiatives to drive quality and culture in order to consistently achieve star rating and quality performance goals. This position includes the ability to utilize population health platforms, analytic tools and various sources of data to identify opportunities in care gaps and quality performance. The Director Clinical Quality, Disease Management and Case Management will be responsible for execution of the organizational strategies related to the Quality program, disease management program and case management program. This role leads the strategy and direction to improve member and provider quality engagement.

The Director Clinical Quality, Disease Management and Case Management will lead, oversee and mentor the clinical supervisors to develop and drive quality subject matter expertise and technical skills development.

RESPONSIBILITIES & EXPECTATIONS:

• Participates in strategic project initiatives, including the design, development, testing, implementation, and ongoing support across quality projects
• Directs the development and advancement of skillsets and business subject matter expertise of the Quality team members
• Works directly and collaboratively with Senior management to develop strategic quality initiatives.
• Contributes to monthly staff meetings, ensuring appropriate information is reported and communicated.
• Maintains mutually beneficial relations with physicians
• Assists leaders in department indicators and compliance activities
• Prepares presentation reports with action plans and evaluations.
• Ensures staff compliance with policies and procedures
• Develops and maintains knowledge of key performance indicators related to Quality including but not limited to CMS Stars, HEDIS, compliance with regulatory agencies, etc.
• Supervises the development and progress of investigative analytics and ad hoc requests as it relates to quality of care and service
• Effectively visualizes and communicates the risks, insights, patterns, and trends from reports and sources, and provides recommendations
• Collaborates directly with internal and external business units to identify opportunities to enhance program outcomes
• Identifies, leads, tracks, develops action plans and monitors for continuous improvement related to quality and star initiatives, work plan and performance dashboards.
• Develops, implements, and executes strategies to improve member experience and quality outcomes by engaging and educating internal stakeholders, vendors, partners, and providers
• Identifies and implements opportunities to streamline and improve processes.
• Builds a first-in-class clinical quality, case and disease management program using creative, innovative strategies and best practices.
• Provides training, orientation, performance appraisals of supervisory staff; Ensures team develops new data competencies.
• Process Improvement: Continuously reviews, recommends and implements improvement steps, as needed or directed
• Oversees the quality clinical team in quality programs
• Portrays professional image: follows dress code; communicates with internal and external customers in a professional manner, including appropriate verbal and written grammar.
• Promotes and demonstrates professional standards to enhance the development of the department.
• Direct the planning, design, and implementation of provider incentive program
• Directs the HEDIS abstraction team to drive medical record review efforts to maximize performance across HEDIS measures
• Collaborates with HEDIS team to improve supplemental data collection, and health equity initiatives
• Leads special projects with cross-functional teams and senior leaders to achieve strategic performance goals
• Manages overall operational budget and staffing needs to meet business and financial performance objectives
• Practices ethical conduct
• Meets acceptable attendance and punctuality expectations (excluding FMLA)

The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified, and shall not be considered as a detailed description of all the work requirements that may be inherent to this position.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. AultCare is an EEO/AA Employer M/F/Disability/Vet.

QUALIFICATIONS:

• Education: Bachelor’s Degree in Nursing, Healthcare Data Analytics, Health informatics, Epidemiology required; Master’s degree preferred in a healthcare field (MPH, MSN, MHA); CPHQ preferred
• Minimum of 5 years’ experience involving analyses of health care data and clinical program development; project management and process improvement experience or any combination of education and experience, which would provide an equivalent background.
• Strong project management, analytical and organizational skills
• Experience working on value-based care or population health programs preferred
• Experience with quality improvement principles, practices, and tools in system design
• Knowledge of physician practices, health care issues, trends, managed-care relationships, and healthcare systems
• Experience implementing aspects of national quality measure initiatives and protocols (through provider groups, payers, state/federal institutions), such as HEDIS, Medicare Stars, etc
• Experience working with health insurance and healthcare quality reporting including healthcare cost and episode groupers, HEDIS, star ratings, case and disease management programs
• Demonstrated organizational, project management and problem solving skills, with the ability to lead a team, prioritize tasks, and see projects through from inception to completion on schedule
• Excellent interpersonal skills for collaborating effectively with a broad range of clinical and professional staff
• Excellent written and verbal communication skills with the ability to convey complex information in a clear, concise manner and produce high-quality documents, reports, and presentations
• Ability to exercise professional judgment in handling sensitive and confidential issues
• Two (2) years of experience utilizing process improvement principles based on Lean and Six Sigma Methodology, which focuses on streamlining and refining work process preferred
• Demonstrated ability to identify, design, and implement process improvements.
• Effective analytical, critical thinking, and problem-solving skills.
• Ability to balance multiple priorities simultaneously to meet deadlines.
• Ability to work closely with executives, leadership, and other business stakeholders to understand, interpret and evaluate business objectives, risks, and constraints.
• Intermediate skill level with Excel, business intelligence platforms, Microsoft Word, PowerPoint
• Understanding of medical terminology and familiarity with medical records and healthcare information systems
• Experience with EMRs, claims data, Commercial and Medicare reimbursement methodologies preferred

WORKING CONDITIONS:

• Office environment with moderate noise level leading to partial work from home environment when appropriate
• Frequent sitting, use of hands/fingers across keyboard or mouse, and long periods working at a computer.
• Occasionally walking, standing, twisting/turning and reaching upward or forward during work day.