VP, Medicare Stars & Quality Mgmt.

VP, Medicare Stars & Quality Mgmt.

Summary of Position:

Responsible for our Quality performance and results across all lines of business (Medicare Stars, Medicaid QIA, HARP Withhold Program, Essential Plan QIA, NCQA Ratings). Provide leadership over projects designed to drive quality performance, reduce administrative and medical costs; improve
core process efficiency, effectiveness and responsiveness; measure and improve business critical operational KPIs/metrics, especially in the areas of customer satisfaction/loyalty/retention. Lead the development of enterprise-wide quality improvement strategies, including developing programs and initiatives to improve the quality of care and services provided to members across all product lines. Support the Enterprise-wide Health disparity & Social Determinants of Health (SDOH) strategy, initiatives and reporting efforts. Oversee enterprise-wide NCQA accreditation and CMS and NY state-specific quality regulatory requirements, ensuring adherence to accreditation standards and requirements. Responsible for our Quality Program (Risk Management, Review Operations, Improvement & Health Promotion, Measurement, Delegation Oversight, and Accreditation). Oversee provider quality collaborative, and key provider Value Based Payment (VBP) programs including the design, execution and reporting of the Provider P4P program and Quality sections of all VBP contracts. Develop Annual QI Program, Evaluation and Work Plan across the enterprise for various LOBs for approval by the QIC and Quality Committees of the Board. Provide day to day leadership and direction to all direct reports utilizing the enterprise’s core values. Ensure corporate, departmental and budgetary goals are met by continuous evaluation, development of process improvement activities and adaptation of best practices. Responsible for our Quality Program (Risk Management, Review Operations, Improvement & Health Promotion, Measurement, Delegation Oversight, and Accreditation). 

Principal Accountabilities:

• Make significant contributions towards short and long-term business initiatives which include Operating Income, Administrative Expenses, Medicare, Medicaid, HARP, Essential Plan, NCQA ratings, and CAHPS performance.
• Identify, hire, & train staff members, developing them into strong leaders and creating high-performing, self-directed teams.
• Effectively plan for succession planning ensuring talent pipeline. 
• Act as change agent to drive and effect organizational change ensuring key deliverables are met.
• Establish data-driven quality initiatives, collaborating with multidisciplinary teams, monitoring compliance with healthcare regulations and championing patient advocacy. Ensure that the functional vision and implementation plans align with the core strategic vision and business objectives.
• Oversee the implementation of a strategic vision for healthcare quality, ensuring adherence to rigorous regulatory standards and fostering a culture of continuous improvement. Perform strategic decision-making, leadership, planning, and prioritization to meet business and quality/compliance objectives.
• Evaluate the quality of patient care and safety. Accountable for understanding, coordinating and measuring performance of internal and external quality and safety requirements. Document improvement action plans for processes and projects assigning the responsibilities to the various teams. Carry out Root Cause Analysis of errors to prepare action plans; coordinate with various internal teams to drive actions.
• Create and communicate a vision for quality within the company, setting goals and recommending organizational changes to achieve these goals. Carry out project review meetings to ascertain progress.
• Create an environment conducive to continuous quality improvement and implement systems to nurture quality excellence.
• Direct activities of company-wide quality staff and departmental activities to ensure product quality through test procedures and processes.

Education, Training, Licenses, Certifications:

• Bachelors required; master’s degree preferred
• 12 – 15 years of managed care experience
• Strong background in clinical, financial, technical and operations management and demonstrated proficiency in business management similar in scope
• Strong knowledge of the clinical practice of medicine, health care delivery systems, utilization methods
• Strong knowledge and understanding of managed care principles and industry evolution

Relevant Work Experience, Knowledge, Skills, and Abilities:

• Strong Analytical skills to collect and analyze information, problem-solve, and make decisions
• Proven ability to interpret and present information to enable senior management and business stakeholders to make sound decisions
• Demonstrated success in creating and maintaining a culture of quality in a large global organization
• Knowledge and experience in performing internal and external quality audits
• Knowledgeable and experienced in planning, coordinating, and leading QMS management reviews
• Root cause / corrective action expertise
• Detail-oriented, analytical, and able to manage multiple tasks in a fast-paced environment
• Well-developed written and verbal communication skills
• Positive, team-focused approach and proven leadership track record, including people development and project management

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws