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Director of Quality Management - Clinical Quality/HEDIS

- Fulltime  

Director of Quality Management - Clinical Quality/HEDIS

Pay up to $110k annually DOE - Excellent Benefits

The Quality Management Director is responsible for leadership, management, and oversight of quality functions in support of the organization’s mission and vision This position is key to the development and implementation of the quality improvement strategic plan. This position has direct fiscal responsibility for all functions which fall under his/her supervision.

The responsibilities of this role include but are not limited to collaboration with key departments and external stakeholders, enhancing operational processes, and the development of policies and protocols for improved quality. This position is also required to be familiar with contractual and regulatory requirements.


Essential Functions:

The Clinical Quality and HEDIS QM Director is responsible for (though not limited to):

· Manage and oversight of Clinical Quality and HEDIS functions.

· Develop a standardized quality management plan and strategy program to ensure compliance with regulatory and accreditation requirements.

· Provide oversight of monitoring systems for quality improvement activities.

· Ensure high risk and unusual events are monitored concurrently and retrospectively as they occur.

· Research and develop performance measurement and outcome studies to assess and improve the health status of the membership. Plans, organizes, and manages the design, development and analysis of a wide variety of topics relevant to health care services.

· Design and develop methodologies for preventive care and health care evaluations. Researches and documents current health care standards for use in study design and methodologies.

· Conducts preventive studies to evaluate the continuity and coordination of care and to assess the quality and utilization of health care services.

· Provides guidance to clinical staff regarding study design, methodology, data analysis and reporting.

· Maintain a knowledge base of HEDIS requirements and implements clinical performance methods to improve HEDIS performance.

· Prepare and present executive and detail level summary of quality activities as needed.

· Prepare, compile, review, and present reports to the Continuous Quality Improvement Committee and executive leadership as requested and/or scheduled.

· Provide oversight of training for staff and the provider network on various topics and QM functions.

· Work in collaboration with other departments to develop quality solutions.

· Provide QM representation and or lead Cross-Functional committees as assigned.

· Oversight of applicable policies and procedures.

· Oversight of contractual and Accreditation performance metrics.

· Attend State meetings as needed to stay informed of changes in clinical best practices, performance metrics, local, State, Federal, and Division requirements.

· Performs other duties as assigned.


· Must be knowledgeable about the rules/regulations and clinical practices that guide the services provided.

· Must have experience working with HEDIS software vendors (management, building relationships, issue resolution, etc.).

· Must possess strong clinical knowledge of the treatment/service needs of the persons served and possess skills in assessing strengths and needs, treatment plan development, and clinical service implementation.

· Must possess strong leadership skills and be able to be effective in getting tasks done while working through other people.

· Ability to develop and implement strategic goals and plans.

· Must provide management and oversight of the CQI processes.

· Ability to effectively present information and respond to questions from internal and external stakeholders.

· Must be self-motivated and able to work with a wide variety of individuals and possess the ability to negotiate

effectively in working with teams, providers, and other departments to address issues of concern.

· Must possess organization skills that allow a balance a wide variety of tasks in a time-effective manner.

· Ability to retain large amounts of information and be able to interpret written rules/regulations and make them applicable to others in a manner that meets their position and learning style.

· Detail-oriented, able to independently organize and manage multiple tasks.

· Must also be a resourceful problem solver who thrives in a fast-paced environment.

· Demonstrate proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) and be able to quickly

learn new software tools.

Education and Work Experience:

Education: Applicant must hold a Nursing Degree (RN) and must have a current and active license in good standing through the NC Board of Nursing.


· Experience in quality improvement, analysis, development, public health or related area

· 5 + years of providing supervision and project management experience

· Healthcare/Health Plan experience preferred

· 2+ years of HEDIS experience and/or knowledge

· Specialization area of Psychiatry is desired.

· Experience in behavioral health and Quality Management is highly preferred.