Director of Quality Improvement and Compliance

About This Role

Lead the Quality Improvement (QI) Department for a non-profit organization ensuring compliance with government contracts, policies, and regulations while focusing on continuous quality improvement methodologies.

Responsibilities

• Ensure compliance and adherence to state and local policies are monitored according to guidance and regulations
• Monitor progress towards achieving performance measures for children such as NCQA, NYS HEDIS and QUARR measures
• Ensure the Health Home CMA network adheres to NYS DOH Health Home policies and standards through routine audits, investigations, and data analysis
• Serve as the Designated Compliance Officer for OMIG self-disclosures, investigations, reporting of Fraud, Waste and Abuse (FWA), and HIPAA risk assessments
• Implement Continuous Quality Improvement (CQI) methodologies throughout the organization and network
• Execute and maintain compliance with CCF’s Compliance Plan
• Prepare regular status reports on program performance and issues requiring additional oversight
• Serve as the lead contact for all external oversight entities for audits and implement corrective action plans
• Oversee the development of compliance policies, procedures, and programs and provide guidance to the CCF Health Home CMA network
• Develop measurement tools for quality performance, conduct internal compliance chart reviews, and investigate complaints

Requirements

• Master’s degree with a minimum of 5 years of experience in Public Policy/Administration, Sociology, Management, Statistics, Data Science, Economics, or related field
• A minimum of 2 years of direct supervision and management of individuals and teams
• Knowledge of Office of Medicaid Inspector General (OMIG) rules and regulations
• Experience managing large data sets with Excel, creating pivot tables, using sorting/filtering criteria and creating reports for executive leadership
• Comfortable with Billing Data Concepts (Accounts Receivable, Claims, Remittance, Denials, etc.) as it relates to Medicaid billing
• Knowledge of the NYS Medicaid eligibility requirements and benefits
• Knowledge with government contract billing and reimbursement
• Ability to manage overview of billing workflows

Qualifications

• Master’s degree in Public Policy/Administration, Sociology, Management, Statistics, Data Science, Economics, or related field
• 5+ years of experience in Public Policy/Administration, Sociology, Management, Statistics, Data Science, Economics, or related field; 2+ years of direct supervision and management of individuals and teams

Nice to Have

• Certified Microsoft Power BI (PBI)
• Knowledge and understanding of Medicaid Billing
• Understanding of NYS Health Home service concepts in relationship to billing requirements
• Microsoft proficiency: Word, Excel, PowerPoint
• Knowledge of developing queries or dashboards in an interactive database such as Microsoft Power BI, Tableau

Skills

* Required skills

Certifications