Director of Quality and Clinical Performance - Medicaid

Company: Adobe CW
Location: Mesa
Posted on: September 24, 2022

Job Description:

ABOUT

Adobe Care & Wellness began as an idea for a healthcare solution dedicated to improving lives through a holistic and integrative healthcare model. Founded in 2018, ACW is based out of Tempe, AZ, with multiple sites throughout AZ and NV. We are an integrated health solutions company that specializes in customizing programs for insurance groups, providers, hospitals, and families and are the only fully integrated healthcare provider in the nation. With a driving mission to positively impact the lives we touch, ACW now supports and serves over 50,000 individuals through a variety of eight programmatic offerings. As we continue to grow to serve those in need, we are looking for the people who want to make a difference.

SUMMARY

The Director of Quality has oversight over a Medicaid contract and the performance of clinical services. The Director of Quality is responsible for the development and oversight of quality operations, monitoring program results against targets, ensuring regulatory and internal goals are met which includes fiscal accountabilities, and establishing and maintaining an effective interface with internal and external groups which impact quality management goals and objectives. The Director of Quality will assist in developing and implementing systems that will improve quality, increase efficiency, and drive cost savings.

As the Director of Quality, you will be accountable for conducting thorough business case and customer value analysis to identify appropriate quality and population health programs as well as executing the design process based on a structured and analytical approach. The Director of Quality will foster strong, ongoing relationships among internal and external business partners by leveraging their subject matter expertise and thought partnership, transferring knowledge, best practices (external and internal), methodology, and tools. In this role, the Director of Quality will lead the team in defining improvement objectives focused on clinical gap closure, health outcomes, and improved member experience. This newly created position supports ACW s Medicaid contract and reports to the VP of Operations.

DUTIES

• Responsibilities include leading assessments to identify the appropriate programs and communicating recommendations to a variety of internal partners and leaders
• Responsible for facilitating meetings to secure external contracts
• Responsible for concurrent initiatives as team lead and/or team member, based on resource 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 overread processes.
• Knowledge of healthcare claims, surveys, clinical, and health data
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence
• Conducts member and provider outreach designed to close member gaps in care, documenting such efforts in a manner that allows collaboration with other team members and other member-facing care delivery staff
• Analyzes quality reports and claims data to assess up-to-the-minute member compliance status to a wide variety of quality measures, utilizing this information to improve compliance and member health outcomes
• Collaborates with a variety of in-home & community-based providers to locate non-compliant members, managing member referrals to those providers for a variety of gap-closing quality campaigns
• Maintains access to provider reporting of gap-closure outcomes and facilitates the transmission of such information as supplemental data
• Maintains ongoing subject matter expertise in population health, measurement science, accreditation, and quality improvement
• Managing Medicaid quality program measures that may include but are not limited to;
• Breast cancer screenings
• Child and adolescent well visits
• Prenatal and postpartum care
• Post-hospitalization visits
• Ensuring the success of visits
• Leading meetings regarding the progress of the contract with the health plan
• Responsible for leading meetings regarding the progress of the contract with the health plan
• Use data to drive decisions, plan and implement performance improvement strategies for clinical functions and activities
• Participate in peer review activity as appropriate
• Perform random clinical quality audits
• Participate and oversee Quality Assurance/Quality Improvement programs and initiatives for their region and prepare any necessary reporting for the Quality Assurance Committee
• Other duties as assigned
  
  SKILLS
  
  • A self-motivated and meticulous individual
  • Be systematic, highly organized, and able to articulate thoughts
  • Extensive knowledge of quantitative and qualitative research methods
  • Excellent organizational and time management skills
  • Flexible with proven ability to conform to shifting priorities, demands, and timelines.
  • Support internal quality systems, and internal audits, and assist with investigations of nonconforming material
  • Technically competent with various software programs including but not limited to MS Office (Excel, Word, PowerPoint)
    
    QUALIFICATIONS
    
    • Bachelor's Degree required
    • Master s Degree preferred
    • 5+ years of clinical experience
    • 3+ years related to managing an organization's quality improvement plan
    • RN or Health Care Administrator preferred
    • Progressive experience in the health solutions industry, with emphasis on leading and managing teams
    • Prior Medicare/Medicaid experience
    • Prior managed care experience
    • Experience developing and implementing clinical, service, and operational processes improvement initiatives, both small and large scale
    • Able to read and understand procedures and inspection criteria
    • Extensive knowledge and experience with Medicaid
    • Extensive knowledge and experience with HEDIS/Stars and CMS quality measures
    • Extensive knowledge and experience AHCCCS Associated topics: commission, customer, insurance agent, life insurance sales, outside sales, phone, sales associate, sales position, sales representative, sell

Keywords: Adobe CW, Mesa , Director of Quality and Clinical Performance - Medicaid, Executive , Mesa, Arizona