responsible for driving the development, coordination, communication, and implementation of a strategic clinical quality management and improvement program within assigned health plan.
working with the regional head of quality management to direct the clinical quality initiatives, including HEDIS and CAHPS quality improvement, NCQA accreditation and compliance with regulatory agencies and other objectives.
works with both internal and external customers to promote understanding of quality management activities and objectives within the company and to prioritize departmental projects according to corporate, regional, and departmental goals.
maintains expert knowledge of current industry standards, quality improvement activities, and strong medical management skills.
serves as a resource for the design and evaluation of process improvement plans/quality improvement plans and ensures they meet Continuous Quality Improvement (CQI) methodology and state contractual requirements.
collaborates with other leaders in developing, monitoring, and evaluating Healthcare Effectiveness Data Information Set (HEDIS) improvement action plans, year-round medical record review, and over read processes.
monitors and reports quality measures per state, Centers for Medicare and Medicaid Services (CMS), and accrediting requirements.

Requires BA/BS in a clinical or health care field (i.e. nursing, epidemiology, health sciences)
Minimum 5 year progressively responsible experience in a health care environment or any combination of education and experience, which would provide an equivalent background.
Knowledge and experience with Ohio Department of Medicaid’s Quality Withhold Programs strongly preferred.
Extensive knowledge of Ohio Department of Medicaid’s Quality expectations strongly preferred.
Proven experience utilizing data analysis to drive quality improvement initiatives strongly preferred.
Proven experience leading providers, community partners, and shareholders in initiatives to close gaps in HEDIs rates strongly preferred.
Experience effectively deploying quality tools ex. Key Driver Diagrams, Fishbone, Voice of Customer, Run Charts etc. is a plus.

Medicaid Quality Management Director

Key skills