Director, Quality Management

Role Overview: The primary purpose of the job is to be responsible and accountable for the successful, ongoing development, refinement, implementation, measurement, quality improvement and effectiveness of Long Term Services & Support (LTSS).

Work Arrangement:

• Remote - This position is fully remote, and the Associate must be in Pennsylvania (PA)
• Travel to state & leadership meeting as needed.
• Reliable high‑speed internet required (minimum 50 Mbps download / 5 Mbps upload)
• Associates residing in states where reimbursement is required by contract, law, or regulation may submit eligible expenses for reimbursement

Responsibilities:

• Overseeing quality management for Long Term Services and Supports (LTSS) in PA
• Accountable for ongoing maintenance of the Plan's compliance with state regulations and National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC) and other appropriate standards for activities related to Quality, Care Management and Utilization Management.
• This includes credentialing/re-credentialing activity, delegation oversight, quality of care investigations as well as the corresponding inter- and intra-departmental coordination, communication, and education.
• Oversight and responsibility for the Plan's, Line of Business or Product Line's QAPIC Committee structure and support.
• Works directly with Senior Executives to plan, organize and direct the identification, prioritization and implementation of strategic projects that improve financial, service and clinical outcomes for the Plan, LOB or Product Line.
• In coordination with Plan stakeholders, develop, implement and lead strategy to improve HEDIS outcomes and maximize pay for performance payout and reduce withholds and/or liquidated damages
• Provides functional support to the Network Management, Informatics, Information Solutions, Care Coordination, Utilization Management, and Public Affairs departments to integrate Quality Management initiatives and goals with organizational programs.

Education & Experience:

• Bachelor's degree required
• An active unrestricted licensed Registered Nurse (RN) in PA or healthcare quality certification such as American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or Certified Professional in Healthcare Quality (CPHQ) in accordance with state specific requirements
• 1 to 3 years of experience in Medicaid.
• 5 to 10 years of experience in a clinical setting
• 5 or more years of experience in managed care and leadership.
• Prior URAC or NCQA Accreditation experience

Skills & Abilities:

• Strong leadership and people-management skills, with the ability to supervise, coach, develop, and provide performance feedback to quality management staff.
• Extensive knowledge of healthcare quality assurance, quality improvement, outcomes management, and performance improvement principles and practices.
• Ability to develop and present comprehensive quality reports, analyses, recommendations, and performance findings to leadership and cross-functional stakeholders.
• Strong project and program management skills, with the ability to manage multiple quality initiatives, priorities, deadlines, and contractual deliverables.
• Excellent verbal and written communication skills, with the ability to communicate effectively with internal teams, leadership, providers, and external stakeholders.
• Strong presentation and facilitation skills, including the ability to communicate complex quality and clinical information clearly to varied audiences.
• Demonstrated problem-solving, critical-thinking, and independent decision-making skills.
• Ability to identify opportunities for process improvement and lead the development and implementation of improved clinical and administrative processes.
• Strong interpersonal and conflict-resolution skills, with the ability to effectively manage difficult or sensitive situations.
• Ability to collaborate across departments and build strong working relationships to support organization-wide quality improvement initiatives.
• Strong organizational and time-management skills with excellent attention to detail.
• Proficiency with Microsoft Office applications and the ability to effectively use technology for reporting, data analysis, documentation, and communication.