Director of Quality & Outcomes - Health Plan

We are looking for a Director of Quality & Outcomes Management – Health Plan, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will be responsible for planning, organizing, developing, and assessing the success of health plan quality improvement program and workplan. Responsible for coordinating the development and implementation of provider and administrative strategies for monitoring and improving outcomes by enhancing the quality of care and services rendered to members. Will provide leadership and consultation to Health Plan departments in maintaining all activities related to NCQA & HEDIS accreditation. Managed Care - Health Plans experience a must.

Skills & Requirements

• Required Bachelor's degree Nursing - Master's degree preferred
• Required 5 yrs of Managed Care experience
• Required RN - Lic-Registered Nurses by the Texas Board of Nursing or Nursing Licensure Compact 
• Required 7 years of experience in quality improvement, medical management; including two years of management/leadership experience 
• Preferred CERTPHQ - Cert Profess in Healthcare & Qual by the National Association for Healthcare Quality 
   

Job Duties & Responsibilities

• Continuously evaluates and updates the HP Quality Improvement Program and Workplan based upon data-driven assessments of the health needs/outcomes of members, accreditation, regulatory and contractual requirements. 
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Provides oversight for maintenance of Quality Dashboards, including HEDIS Measure performance, for Executive Leadership. 
• Provides organizational leadership for all activities related to the on-going National Committee for Quality Assurance accreditation. 
• Coordinates the Quality-of-Care report processes to meet regulatory and contract requirements.  
• Oversees quality management staff and coordinates departmental functions with Care Management, Claims Administration, Network Development, Information Systems, Member Services, Finance, and the Integrated Delivery System.  
• Provides leadership for multiple essential committees in the health plan infrastructure. 
• Coordinates the delegation oversight processes for selected vended services including vision and dental; ensuring oversight complies with all accrediting, regulatory and contractual requirements. 
• Oversees health plan credentialing functions, including delegated credentialing for all delegated entities, ensuring oversight complies with all accrediting, regulatory and contractual requirements.  
• Oversees regulatory and other survey assessments of the accessibility, quality of care and service for health plan members. 
• Leads the ongoing professional monitoring, documentation, and evaluation of both the annual Quality Assessment and
• Performance Improvement Plan and the annual HHSC Performance Improvement Plans to assure progress to goals and compliance with regulatory requirements. 

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