Director, Care Management & Quality

About This Role

This role will lead the people, process, and business requirements to manage care, spearhead the plan's HEDIS/Stars program, and provide exceptional customer service. This Director will be an integral member of the health plan's senior leadership team, responsible for developing and implementing clinical intervention strategies.

Responsibilities

• Lead the development and implementation of clinical intervention strategies tailored to defined populations
• Collaborate across care teams to identify optimal clinical support and programming
• Oversee clinically integrated programs for capitation members and lead operational improvement initiatives
• Deploy resources to support measurable improvements in health outcomes, member experience, and cost efficiency
• Develop and execute an annual population health improvement plan, incorporating clinical strategy to assess intervention effectiveness
• Develop and evolve the population health strategy framework for member/patient management and engagement
• Provide leadership, direction, guidance, clinical expertise, and consultation to population health program staff
• Develop strategic direction for Star Rating improvement through ongoing execution and program standardization for Clinical HEDIS stars measures
• Collaborate and facilitate activities with other units for intervention development and execution to support Medicare Stars measure level improvement
• Serve as a subject matter expert and represent the Clinical department in meetings and discussions related to HEDIS stars management

Requirements

• Bachelor's Degree in Healthcare Administration, Public Health, or related field
• 5+ years of prior management experience in Care Management and/or Quality in a managed care setting
• 8+ years of experience working in Care Management or Quality
• 3+ years of experience in population health, healthcare, HEDIS, HOS, CAHPS, STARS or QRS
• 5+ years of Managed care experience across a broad portfolio of products or provider managed care setting, specifically with state and federal health programs
• 5+ years of experience with care management principles, population health management, CMS guidelines, regulations, NCQA and HEDIS standards/guidelines

Qualifications

• Bachelor's Degree in Healthcare Administration, Public Health, or related field.
• Five (5) years of prior management experience in Care Management and/or Quality in a managed care setting, eight (8) years of experience working in Care Management or Quality, three (3) years of experience in population health, healthcare, HEDIS, HOS, CAHPS, STARS or QRS, five (5) years of Managed care experience, and five (5) years of experience with care management principles, population health management, CMS guidelines, regulations, NCQA and HEDIS standards/guidelines.

Nice to Have

• Current unencumbered licensure as a Registered Nurse professional with the WV Board of Registered Nurse Professional Nurses or appropriate state board, OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• Master of Science in Nursing (MSN)
• Care Management and/or Quality for Medicare and/or Medicaid populations
• Leading care management or population health management program development to address the health of a managed care population
• 5+ years of clinical experience, with at least 2 years in care management, case management, or population health
• HEDIS quality measurement knowledge or experience
• Leading and collaborating with others on National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance
• Excellent communication, coaching, and organizational skills

Skills

* Required skills