Sr. Director, Clinical Quality Governance & Regulatory

Job Summary:

The Senior Director, Clinical Quality Governance & Regulatory will provide strategic oversight for clinical quality, patient safety, risk management, credentialing, peer review, and regulatory compliance. This senior leader will serve as a key partner to local and national boards, ensuring effective governance, quality performance, and accountability across health plan and care delivery operations.

In addition to the responsibilities listed above, this position is also responsible for overseeing clinical quality and patient safety management programs including budgets, annual evaluations and revisions, preparation of internal/external reports, consultation services, education initiatives, measurement of outcomes, and improvement strategies related to clinical, accreditation, regulatory and licensing (AR&L), risk management, and infection prevention and control; establishing standards and strategies for the evaluation, design, development, and implementation of evidence-based guidelines, principles, and/or programs related to area of work as well as to reduce variation in clinical practice, optimize patient outcomes, and ensure organizational compliance; leading the collection, analysis, reporting, and presentation of clinical data to identify trends, outliers, and areas for improvement to inform high-visibility, long-term strategy and project goals; developing strategies for education initiatives regarding quality improvement activities, changes to existing processes to meet regulatory requirements, and translating external demands into program goals; serving as a strategic expert on the monitoring, reporting, and development of mitigation plans for all occurrences which may lead to medical center liability; supporting the medical centers continuous survey readiness program to maintain compliance with regulatory standards; and developing strategic relationships with applicable government agencies, regulatory agencies, and other organizations.

Essential Responsibilities:

• Builds organizational capacity and prepares high potentials for growth opportunities and advancement; builds collaborative networks inside and outside the organization for self and others. Provides framework for soliciting and acting on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement. Models and drives continuous learning and oversees the recruitment, selection, and development of talent; stays current with industry trends, benchmarks, and best practices; ensures performance management guidelines and expectations to achieve business needs. Acts as a thought leader on industry trends, benchmarks, and best practices; shares best practices within and across teams to drive improvement. Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning cross-functional resource plans with business objectives. Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact across teams.
• Oversees the operation of multiple units and/or departments by identifying member and operational needs; ensures the management of work assignment allocation and completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Engages strategic, cross-functional business units to champion and drive support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and ensures resolution of escalated issues. Sets and communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; obtains and distributes resources. Anticipates and removes obstacles that impact performance; addresses performance gaps and implements contingency plans accordingly; ensures teams accomplish business objectives; serves as a subject-matter expert and trusted source to executive leadership; provides influence and consultation in the development of the larger organizational or business strategy.
• Directs data collection and analyses to support quality improvement reporting by: overseeing statistical analysis for quality improvement evaluations, special projects, and other work for multidisciplinary review; establishing the long-term plans for the integration and use of multiple utilization data reporting systems to develop and maintain a variety of statistical reports to support evidence driven improvement across KP; presenting and interpreting quality improvement metric reports to executive management to demonstrate improvements and effectiveness of quality improvement programs to a variety of technical and nontechnical audiences, such as executive management and external agencies; and serving as a technical expert to executive internal and external stakeholders by advising on strategies to improve data collection, analysis, and reporting, at the organizational level to monitor success of long-term success of KP goals/objectives.
• Oversees current and director future quality improvement and improvement risk management efforts by: implementing corrective action plan for improvement identified through utilization review, clinical records audit, claim denials, member satisfaction surveys, and auditing surveys at the executive level to guide long-term strategies and policies; ensuring current and future process improvement initiatives are compliant with established internal and external regulation requirements; utilizing information gathered from root cause analysis, failure mode and effect analysis, and other assessments in response to significant events near misses, and good catches to establish new policies and procedures to mitigate future risk; and defining the standards for escalating high-risk issues and trends at the regional and organizational level.
• Oversees quality improvement performance metrics development, collection, and utilization at the organizational level to guide future policy and strategy by: consulting with executive management for the effective integration of performance metrics, standards, and methods to establish improvement success across KP; consulting with executive stakeholders often with competing/conflicting objectives, to ensure development of cohesive and reachable metrics are practical, meet multidisciplinary standards, and are adaptable; and monitoring the delivery of measurable results and alignment with strategic objectives by advocating for the integration of metric utilization into workflows, and providing expertise in the development of project structure, charters, metrics, and work agreements across multiple, complex project lifecycles.
• Oversees the future direction of quality improvement initiatives and their integration into KP strategy by: driving the long-term direction for the use of technology, methods, and tools to develop stakeholders capabilities for process improvements; serving as the technical advisor to internal and external stakeholders on advanced data-driven improvement principles, tools, and problem-solving methods, including Lean/Six-Sigma concepts and techniques using quality improvement metrics; establishing milestones, detailed workplans, and documentation practices in order to create a clear, logical, and realistic plans that guide the future direction of KP; and consulting with internal and external stakeholders, to define the strategies for quality improvement processes to have consistent design and application of improvement methodologies, use of technology, and prioritization of adaptability.
• Serves as the subject matter expert for quality improvement processes and regulations for executive internal and external stakeholders, executive sponsors, business owners, and external quality improvement organizations by: providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation and advises on the long term strategies of KP to address the current climate and potential changes which may have long term effects on business operations; proactively engaging internal and external committees, projects, and relevant initiatives to actualize change and determine necessary infrastructure changes to move QA initiatives forward and ensure future KP compliance; maintaining collaborative, results oriented partnerships to ensure current and future compliance and influences the development and direction of KP policy and strategy to be compliant and adaptive; forecasting and determining the direction of future educational programs to raise awareness for current and changes in regulation requirement, internal concerns, and system/database usage; and identifying and removing barriers to process improvements issues and weighs practical, technical, and KP capability considerations in addressing issues and advises on policy changes.
• Oversees and empowers continuous learning in stakeholder development through quality performance review processes by: forecasting and revising the processes and standards for utilization and performance reviews at the organizational level by utilizing multidisciplinary criteria and guidelines, and takes a systematic approach to quality improvement; developing the standards for performance at the organizational level and sets the standards for corrective action plans; presenting performance review reports at the organizational to executive management and external agencies, and advises on the integration of best practices and future performance review needs; and defining the standards for all training and educational programs related to process improvement for quality improvement programs at the organization level.