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   Current UPMC employees must apply in HR Direct

Senior Director, Quality Regulatory Affairs, Strategy & Operations

Description

Purpose:

Under the direction of the Chief Quality Officer/Vice President, Quality Performance of the Insurance Service Division, the Senior Director, Quality Regulatory Affairs, Strategy and Operations is responsible for leading, executing, and advancing the organization-wide quality strategy  and optimizing regulatory requirements and performance across all quality rating programs.  The position serves as the subject matter expert in all quality rating programs and is responsible for coordinating all quality improvement program related activities, objectives, and analysis related to ongoing development, maintenance and evaluation of quality operations  and strategies focused on NCQA, HEDIS, and CAHPS for all products and services. Actively supports and collaborates with Medicare Star leadership to assure CMS regulatory requirements are monitored, met and/or exceeded in related star measures. This position ensures strategies meet all quality regulatory requirements. They establish annual work plans and program evaluation, and 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, coordination, 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 leading all operational quality activities, including oversight of regulatory quality requirements for Department of Health and Human Services (DHS) Medicaid, NCQA accreditation, Quality of Care (QOC) concerns, HEDIS, CAHPS and credentialing. Provides subject matter expertise across all quality rating programs and related measure specifications.
  • Responsible for monitoring performance and the achievement of departmental objectives, performance goals, and compliance. Deploys improvement frameworks (i.e. PDSA, Lean, Agile, etc.) and related tools/methodologies to advance performance.
  • Establishes quality improvement objectives, develops, and implements the comprehensive Quality Improvement program to meet the demographic and epidemiological needs of the population served and provide high quality and culturally appropriate care.
  • Ensures compliance with federal, state, and accreditation standards by developing, implementing, and maintaining compliance processes within the department.
  • Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.
  • Promote plan-wide understanding, communication, and coordination of QI programs across all product lines.
  • Responsible for ensuring compliance with all regulators' quality improvement requirements.
  • Responsible for the implementation of a LTSS critical incident process, tracking and reporting.
  • Responsible for ensuring compliance and providing direction and guidance on clinical quality improvement and management program including but not limited to NCQA.
  • 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.
  • Ensure necessary steps are taken to achieve a successful year over year improvement of HEDIS, DHS, and CMS measures.
  • 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)
  • 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.
  • Responsible for the overall development and implementation of all reporting goals focused on clinical, quality, and operational targets.
  • Effectively support activities related to NCQA accreditation.
  • Support the framework for the valid collection of HEDIS information ensuring the process, data, and results are reviewed and analyzed to generate quality improvement activities. Collaborates as a strategic partner with Quality Analytics leadership to advance the HEDIS roadmap related to the regulatory requirements surrounding electronic clinical data system (ECDS) measures and supplemental data sources, such as Health Information Exchanges (HIEs), electronic medical records, and greater alignment with the care management/Health Plan ecosystem (including but not limited to HealthPlaNET).
  • Oversee and provide coaching, development, and overall performance management for the team. Evaluates and communicates overall team performance to the senior team.
  • Assist with implementation of member/provider/community/data interventions that improve health plan performance across all products.
  • Identify opportunities to improve quality of care delivery, outcomes, and leverage data integration.
  • Support clinical improvement initiatives and incentive programs by supporting strategic analysis in collaboration with Quality Analytics leadership in order to provide actionable data in a timely and accurately manner.
  • Support quality strategy for value-based payment models and new methods to measure clinical quality for individual and population health.
  • Identify quality improvement opportunities and effective interventions to meet CMS stars, Department of Health and Human Services, and NCQA regulatory requirements.
  • Strategize enhanced provider reporting automation options, including integrating with the provider electronic medical record systems.
  • Responsible for strategizing, synthesizing, and analyzing data and reporting findings.
  • Identify measures of success for clinical best practices and participates in quality improvement activities.
  • Identify opportunities and support collaborations with other ISD departments, the IDFS, and network that improve quality of care delivery, member experience, and outcomes.
  • Build an amazing team within the strategically targeted growth areas that will deliver quality health outcomes and superior medical expense ratios.

*Performs in accordance with system-wide competencies/behaviors.

*Performs other duties as assigned.

 

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

 

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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