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   Current UPMC employees must apply in HR Direct

Senior Director, Quality Regulatory Affairs, Strategy & Innovation

Description

Purpose:
Under the direction of the Vice President, Quality Performance of the Insurance Service Division, the Senior Director, Quality Regulatory Affairs, Strategy and Innovation is responsible for strategic quality initiative development and the quality management. The position is responsible for development and coordinating all quality improvement program related activities, objectives, and analysis related to ongoing development, maintenance and evaluation of quality systems and strategies focused on NCQA, HEDIS, and CAHPS for all products and services. This position ensures strategies meet all quality regulatory requirements. They establish annual work plans and program evaluation, policies and procedures at all levels to ensure quality programs will 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.In addition, this position provides strategic direction for quality of care delivery, service, innovation and efficiency within the IDFS. The individual will optimize integration across the integrated delivery and finance system and network to improve quality and efficiency of care.

Responsibilities:
  • Overall responsibility for development and management of all strategic quality activities, including oversight of government quality requirements for Medicaid, NCQA accreditation, QOC concerns, HEDIS, CAHPS and credentialing.
  • Responsible for ensuring compliance with all regulators? quality improvement requirements
  • Establishes quality improvement objectives, develops and implements the comprehensive Quality Management program to meet the demographic and epidemiological needs of the population served and provide high quality and culturally appropriate care
  • Responsible for ensuring compliance and providing direction and guidance on clinical quality improvement and management program including but not limited to NCQA
  • Support quality strategy for value based payment models and new methods to measure clinical quality for individual and population health
  • Establish a framework for the valid collection of HEDIS information ensuring the process, data and results are reviewed and analyzed to generate quality improvement activities
  • Support clinical improvement initiatives and incentive programs by providing actionable data in a timely and accurately manner.
  • Identify opportunities and support collaborations with other ISD departments, the IDSF and network that improve quality of care deliver, member experience and outcomes.
  • Oversee and provide coaching, development, and overall performance management for the team. Evaluates and communicates overall team performance to the senior team
  • Responsible for the achievement of departmental objectives, performance goals, and compliance
  • Assist implementation of provider interventions that improve health plan performance
  • Strategize enhanced provider reporting automation options, including integrating with the provider electronic medical record systems
  • Identify measures of success for clinical best practices and participates in quality improvement activities
  • Ensures compliance with federal, state, and accreditation standards by developing, implementing and maintaining compliance processes within the department
  • Responsible for the implementation of a LTSS critical incident process, tracking and reporting
  • Responsible for the reporting and analysis of quality of care concerns and for the development of plans and programs to support continuous quality improvement using HEDIS, CAHPS and other tools
  • Responsible for synthesizing and analyzing data and reporting findings
  • Ensure necessary steps are taken to achieve a successful year over year improvement of HEDIS measures
  • Build an amazing team within the strategically targeted growth areas that will deliver quality health outcomes and superior medical expense ratios.
  • Responsible for the overall development and implementation of all reporting goals focused on clinical, quality, and operational targets
  • Identify opportunities to improve quality of care delivery, outcomes, and leverage data integration
  • Promote plan-wide understanding, communication, and coordination of QM programs
  • Support development of seamless interfaces with all network providers, members, and regulators to ensure quality, coding and related performance metrics are effectively and efficiently managed and reported. (HEDIS, P4P, HCC)
  • Identify quality improvement opportunities and effective interventions to meet CMS stars and NCQA quality-oriented regulatory requirements.
  • Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action
  • Effectively manage activities related to NCQA accreditation
  • Support development of new models, methods, and innovations which strengthen 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.

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 CMS Stars management and knowledge of CMS Stars 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.
  • Understanding of analytics and comfort using data and understanding and meeting regulatory requirements.


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 &emdash; 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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