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   Current UPMC employees must apply in HR Direct

Senior Director, Quality Improvement

Description

The Senior Director, Quality Improvement is responsible for direct oversight, subject matter expertise, and strategic quality improvement/ratings success of the Commercial/Marketplace lines of business, Quality of Care processes, and the Member Complaints and Grievances Department.  Based on the review of data and related industry evolution in quality strategies and measure specifications, the Senior Director strategically develops member, provider, and community-focused interventions and programs that support the success of the health plan Commercial and Marketplace ratings. This role leads matrix collaboration and oversight of Commercial and Marketplace Individual (QRS) product results, regulatory requirements (NCQA Commercial and CMS Marketplace star ratings), integrated operational and clinical teams, and all aspects of quality analysis.

The Senior Director drives an innovative and proactive quality strategy that assures alignment and prioritization across products and quality improvement teams. The position is responsible for coordination and process improvement associated with all quality-of-care concerns in close collaboration with the Chief Medical Officer of Quality Improvement. This includes all activities, objectives, and analysis related to ongoing development, improvement, and evaluation of quality systems and strategies focused on the Quality of Care for all products and services. 

In addition, this position provides strategic direction for quality-of-care delivery, service, innovation, and efficiency across the ISD. The individual will optimize integration across the integrated delivery and finance system (IDFS) and network to improve quality and efficiency of care.  The position is responsible to assure NCQA, CMS, and DHS regulatory requirements are monitored, met and/or exceeded related to Quality of Care concerns and Member Complaints and Grievances. With oversight of the Member Complaints and Grievances team, this position collaborates with Pharmacy, Member Services, Compliance, Legal, and all Product leaders to assure strategies meet all quality regulatory requirements and related process improvements are implemented. 

The position will establish annual improvement plans and program evaluation, policies, and procedures to assure complaint and grievance programs meet or exceed guidelines. This position will not only strategically direct the programs and services that support UPMC Insurance Services Divisions' relationships with its members, providers, staff members, network, and community, but also align with the overall corporate goals and strategies of UPMC.


Responsibilities:

  • Meet all regulatory requirements for all applicable products. Management of quality reporting for Commercial and Marketplace products, ensuring accuracy and timeliness.
  • Responsible for Commercial and Marketplace product annual quality results. Drive implementation of member/provider/community/data interventions that improve health plan performance. Report routine progress, results, strategy for improvement to the Commercial and Marketplace clinical and senior leadership teams. Collaborate with leadership to align key priorities and assure effective execution with clear deliverables and ownership.
  • Supports NCQA and CMS audit readiness, by supporting the ongoing training, competency assessment, mock audits, monitoring of metrics and corrective action in collaboration with the Director of Quality Improvement who oversees all NCQA accreditation standards and related survey readiness.
  • Oversight of Commercial and Marketplace member satisfaction (CAHPS) scores and leading integrated quality improvement work teams focused on member experience. Implement cross-functional work teams to increase all aspects of the HEDIS, CAHPS, and other metrics for Commercial and Marketplace.
  • Partner with subject matter experts in Clinical Operations, Pharmacy, Member Services, Sales/Product, Marketing, Network, Medical Director leadership, and other areas to develop aligned strategies, analyses, and recommendations for improvement. Identify opportunities and support collaborations with other ISD departments, the IDFS, and the provider network that improve quality of care delivery, member experience, and outcomes.
  • Support quality strategy for value-based payment models and new methods to measure clinical quality for individual and population health.
  • Collaborate with population health management strategy and clinical operations to ensure Commercial and Marketplace measures have actionable tactics to drive improved rating performance. Support clinical improvement initiatives and incentive programs by aligning tactics and supporting strategic approaches to improvement.
  • Responsible for strategizing, synthesizing, and analyzing data and reporting findings. Produce executive dashboards, trends, and surveillance reports for senior management and department leaders and teams. Support system enhancements that drive automation, integration, and efficiencies.
  • Review best practices, industry results/learnings, and industry products routinely for new reporting, analysis, and modeling opportunities. Integrate with health plan leaders to collaborate in member incentive decisions and other programmatic interventions where applicable.
  • Responsible for ensuring compliance and providing direction and guidance on clinical quality improvement and management program. Responsible for the oversight, reporting, and analysis of quality of care (QOC) concerns and the development of plans and programs to support continuous quality improvement and an optimal member experience.
  • Related to Member Complaints and Grievances (C&G) and Quality of Care concerns, maintains CMS/DHS audit readiness, with ongoing training, competency assessment, audit, monitoring of metrics and corrective action. Identifies opportunities to align efforts and optimize member experience where complaints and/or quality of care concerns resulted.
  • Lead C&G activities and processes related to implementation, improvement, and overall monitoring of department operations, including but not limited to, staffing ratios, productivity/timeliness standards, root cause analyses, and meeting all regulatory requirements across products. Ensure that the monitoring and education/training process is supportive of achieving targeted results established by the Health Plan and/or regulators.
  • Support development of new models, methods, and innovations which strengthen member/provider/payer/employer/community stakeholder connectivity that enhance the relationship, health outcomes, and affordability of products and services delivered by the Plan to members, providers, and other stakeholders.
  • Build a high performing team across strategically targeted growth areas that will deliver quality health outcomes and cost effectiveness. Develop process to regularly receive ideas on innovation and new methods of improving performance. Support team development, training, and/or mentoring curriculums that teach fundamentals of improvement science, matrix collaboration, and effective improvement frameworks (i.e. PDSA, Lean, Six Sigma, Agile, etc.). Leverage process improvement tools and techniques to drive innovative thinking and a data-driven, rapid cycle approach to quality improvement.
  • Identify opportunities and support collaborations with other ISD departments, the IDFS, and the provider network that improve quality of care, member experience, and outcomes.

 

Qualifications

  • Bachelor's Degree in healthcare administration, nursing, hospital administration, business, public health or related field.
  • Masters preferred, or comparable work experience considered.
  • 7-10 years managed care experience preferred.
  • Multiple years' experience with quality improvement and meeting regulatory requirements.
  • Excellent communication skills; verbal, written, and interpersonal.
  • Strong analytical and problem-solving skills. Strong leadership skills and independent decision-making ability.
  • Computer skills in Word, Excel and Outlook required.
  • Skills/experience in NCQA/HEDIS, CMS, and State requirements for multiple LOBs.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

 

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

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