Director, Quality and Accreditation

Attainment of full compliance with quality performance guarantees and financial incentives through the design and application of plan-wide quality improvement efforts that impact Commercial, Medicaid and Medicare lines of business.

• Lead the development and successful implementation of contractual/regulatory required performance improvement projects, ensuring that resources are properly aligned, business owners are invested, and MGBHP attains full compliance by external auditors. Coordinate with the MGB acute care facilities throughout the project.
• Develop reporting and tracking tools that can be used to effectively monitor and improve ongoing quality improvement projects.
• Implement, monitor, and manage the MGBHP quality management program description, workplan and evaluation across all lines of business (Commercial, Exchange, Medicaid, Medicare Advantage, and Dually Eligible Special Needs Plan), ensuring that quantitative and qualitative performance metrics are consistently met and support attainment of financial incentives and performance guarantees.
• Exhibit leadership and effectively communicate quality improvement projects to senior and executive staff at MGBHP, the MGB delivery system, and external stakeholders, e.g., regulators and governing bodies/agencies.

Manage NCQA accreditation for MGBHP Commercial, Exchange and Medicaid lines of business.

• Lead NCQA health plan accreditation efforts for applicable lines of business, ensuring attainment of 'accreditation' status with each renewal cycle.
• Collaborate and support the Manager of Health Equity and Community Benefits on NCQA health equity accreditation efforts, providing technical support and guidance throughout the process.
• Develop a workplan that outlines efforts, business owners, resources needed, risks and deliverable dates by NCQA standard, ensuring that the workplan is well socialized and properly resourced.
• Manage communications with NCQA, including the application and survey process, ensuring all materials are submitted on time and meet the requirements set forth by NCQA. Build and cultivate relationships with NCQA staff and leadership, acting as plan spokesperson to all levels of NCQA.
• Ensure appropriate checks and balances are in place throughout the life cycle of the NCQA accreditation process, including but not limited to, the use of NCQA auditing of materials and case files, and real time review and vetting of submission materials.

• Communicate NCQA accreditation successes, lessons learned, and opportunities for improvement to all levels of leadership within the plan, MGB and external public and private agencies.
• Support RFP development, including the creation of materials for new and existing clients.

Oversee member satisfaction and experience ensuring maximum performance is achieved.

• Establish a multi-pronged member satisfaction strategy for success across all lines of business (Commercial, Medicaid, Exchange, Medicare Advantage and Medicare Dually Eligible Special Needs Plan), as well as across all levels of leadership.
• Lead the development of a measurement and monitoring system that accurately reports on member satisfaction and can be used as a predictor for annual monitoring.
• Collaborate with health plan departments and network providers to identify best practices, provide educational and training opportunities, and develop new strategies and/or products to reduce member abrasion.
• Identify opportunities for staff training, aimed at improving member experience and achieving 5-star ratings across all areas of health plan operations.
• Provide ongoing updates and strategy to senior and executive level leadership.

Lead the clinical Medicare stars operating model in collaboration with the Stars program manager.

• Execute and lead a clinical Medicare Stars operating model (clinical quality, member satisfaction, population health, pharmacy, and appeals and grievances) for both a Medicare Advantage and Dually Eligible Special Needs Plan.
• Identify points of collaboration with the MGB delivery system and leverage existing best practices that can support 5-star performance across all Star rating measure domains.
• Leverage appropriate technology to monitor real time performance and develop strategies to 5-star success within the clinical domains.
• In collaboration with the Senior Director, effectively communicate performance, strategy, and long-term vision of clinical Star performance to senior and executive leadership throughout the company.

Manage staff and promote positive culture in Clinical department.

• Oversee a team of diverse staff that includes leaders, individual contributors, technical and non-technical staff.
• Recruit and retain high performing team members.
• Ensure resources are deployed to highest value functions.
• Establish and meet internal key performance indicators.
• Encourage and facilitate staff growth and development.
• Promote a team environment.
• Model and promote effective change management techniques.
• Implement and standardize best practices such as process maps, root cause analysis, and Lean methodologies.

Increase integration between Mass General Plan and delivery system.

• Establish positive relationships with delivery system leaders.
• Enhance credibility of Plan
• Develop service levels, key performance indicators and targets for individual and shared activities.
• Promote a seamless experience for our members.
• Identify, share, and implement best practices.
• Leverage unique skills and strengths within each area.
• Build efficiencies between teams.

Use Mass General Brigham healthcare values to govern decisions, actions, and behaviors.

• These values governhow we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration

Other duties as assigned.

Qualifications:

Required:

• Bachelor's Degree required.
• 7 -10 years' experience in one or more of the following: quality management, NCQA health plan accreditation, member experience or Medicare/Medicaid program development, with minimum 5 years supervisory/management experience.
• Track record of achieving high ratings in quality, accreditation, or Medicare stars
• Excellent quantitative and qualitative analytical skills
• Experience presenting large scale and clinically complex programs effectively to senior leadership.

Preferred/Desired:

• 3-5 years Health Insurance or Managed Care experience.
• 3-5 years' experience managing quality programs and NCQA health plan accreditation in the Medicaid/Medicare space.
• Master's degree in a related field.

Skills/Abilities/Competencies:

• Verbal and written communication proficiency.
• Demonstrate the ability to multi-task and problem solve.
• Expertise in staff management, coaching and motivation.
• Strong collaboration and team building skills.
• Competence in documentation, health plan benefit management, regulations/compliance.
• Work with minimal direct supervision.
• Web based research, analytic ability, project management, computer proficiency.
• Demonstrate Mass General Brigham Health Plans core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and collaborating with employees and the people we serve.
• Strong, demonstrated history of an ability to execute on time, on budget, and on scope.
• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."
• Ability to develop, introduce, defend, and gain support for new ideas and approaches.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills.
• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Unquestionable integrity.

Supervisory Responsibilities:

• Supervision of 5 -7 staff.
• Motivates and encourages staff; leads through change and adversity.
• Sets clear goals and objectives and uses metrics to measure performance and hold staff accountable. Provides coaching to improve performance and holds regular development discussions with direct reports. Recognizes staff for their contributions.
• Make decisions that put the needs of the people we serve-our members, providers, brokers, and employers-front and center.
• Communicate and cascade information to employees in a timely manner and actively participate in the success of cross-organizational programs and initiatives.
• Identify/create processes and align resources to accomplish key objectives; clearly convey and assign clear accountability for important objectives, deadlines, and expectations.
• Hire, participate in, and/or recommend development measures and disciplinary actions up to and including termination; evaluate performance and supervise the work of all direct and indirect reports following established organizational policies, procedures, and practices.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.

Working Conditions:

• Normal office working conditions.
• Remote, Hybrid or onsite.
• Occasional travel may be required.

Physical Requirements

• Standing Frequently (34-66%)
• Walking Frequently (34-66%)
• Sitting Occasionally (3-33%)
• Lifting Frequently (34-66%) 35lbs (w/assisted device)
• Carrying Frequently (34-66%) 20lbs - 35lbs
• Pushing Occasionally (3-33%)
• Pulling Occasionally (3-33%)
• Climbing Rarely (Less than 2%)
• Balancing Frequently (34-66%)
• Stooping Occasionally (3-33%)
• Kneeling Occasionally (3-33%)
• Crouching Occasionally (3-33%)
• Crawling Rarely (Less than 2%)
• Reaching Frequently (34-66%)
• Gross Manipulation (Handling) Frequently (34-66%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Feeling Constantly (67-100%)
• Foot Use Rarely (Less than 2%)
• Vision - Far Constantly (67-100%)
• Vision - Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing Constantly (67-100%)