At UPMC, we are committed to keeping our communities safe and healthy as the COVID-19 pandemic continues to evolve. As our recruiters work to fill positions during this time, interviews and recruitment-related processes have been modified to protect and prioritize the safety of our candidates and employees.

UPMC continues to comply with any governmental guidance related to local, state, and federal COVID-19 vaccination and testing requirements where our team members live and work. UPMC strongly supports vaccination and encourages everyone who can get vaccinated to do so to protect themselves, their co-workers, and our patients. At this time, the COVID-19 vaccination is available for new or existing employees on a voluntary basis, except where required by local, state, or federal authorities. Staff in positions in our New York, Maryland, and City of Philadelphia areas must be in compliance with local COVID-19 mandates.

For more information about UPMC’s response to COVID-19, please visit upmc.com/coronavirus.

Search Our Jobs

   Current UPMC employees must apply in HR Direct

Director, Commercial & Marketplace Quality Program

Description

The Director of Commercial & Marketplace Quality Programs will provide direct oversight and subject matter expertise surrounding the quality rating success in Commercial and Marketplace lines of business. Based on review of data and related industry evolution in quality strategies and measure specifications, the 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, integrated operational and clinical teams, and all aspects of quality analysis/reporting. This role drives an innovative and proactive quality strategy with a focus on alignment and prioritization across multiple products and quality improvement teams

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 HEDIS/CMS rate results and leading integrated quality improvement work teams, excluding Medicare, Special Needs Plan, and Government products.
  • 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.Implement cross-functional core teams to increase all aspects of the HEDIS, CAHPS and other metrics for Commercial and Marketplace.
  • 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.
  • Partner with subject matter experts in Clinical Operations, Pharmacy, Member Services, Sales, Marketing, Business Transformation Office, 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.
  • 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.
  • 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.
  • Key team member in determining reporting and utilization of social determinate data in assisting members and increasing measure scores.Proactively analyze and implement actions related to network expansion efforts as it relates to Commercial and Marketplace products.
  • Collaborate with population health management strategy and clinical operations to ensure Commercial and Marketplace measures have actionable tactics to drive improved rating 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.
  • Produce dashboards, trend, and surveillance reports for senior management and department leaders and teams.Support system enhancements that support gap closure automation such as EMR feeds and electronic extraction.
  • Conduct data analysis including demographics, disparities, and social determinants to determine new quality improvement strategies.In collaboration with Marketing and respective clinical leaders, explore enhanced messaging techniques and technology for members and providers related to HEDIS measures.

 

Qualifications

  • Bachelor's Degree in healthcare administration, nursing, hospital administration, business, public health or related field.
  • Masters preferred, or comparable work experience considered. 6-8 years of relevant experience; managed care preferred.
  • Demonstrated experience with NCQA/CMS quality improvement regulatory requirements.
  • Excellent communication skills, including verbal, written, and interpersonal.
  • Above average analytical and problem solving skills.
  • Strong leadership skills and independent decision making ability while driving team empowerment and organization-wide collaboration.
  • Computer skills in Word, Excel, PowerPoint, and Outlook required.


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