Director of Medicaid Quality Improvement

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Director of Quality Improvement is responsible for leading the Medicaid and ACA/Marketplace Quality Improvement Programs for multiple states, including Massachusetts and New Hampshire. They will provide strategic direction and manage organization-wide, cross-functional programs of significant complexity, risk and cost. They are responsible for ensuring compliance to state contractual quality requirements and accountable for meeting quality improvement goals, including quality withhold and quality incentive targets.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

* Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.

* Designs, implements and leads continuous quality improvement strategy and initiatives for Medicaid and Marketplace, driving improved quality performance and achieving corporate quality goals

* Monitors and analyzes quality performance metrics, including Star ratings, identifying opportunities for improvement and monitoring effectiveness of interventions/programs

* Performs root cause analyses and develops action plans to address performance gaps

* Ensures compliance with all relevant federal, state and local regulations, including CMS and NCQA standards

* Maintains complete oversight of the Quality Improvement Program, including development of supporting documentation, policies, procedures and other deliverables

* Oversees quality improvement vendors to ensure all SLAs are being met to achieve organizational quality improvement goals.

* Subject Matter Expert for state contractual requirements related to quality improvement

* Co-lead various regulatory audits to ensure complete and accurate compliance reporting.

* Coordinates internal and external reporting requirements with appropriate departments for complete and accurate data reporting.

* Collaborates across the enterprise to align quality initiatives and acts as SME for clinical and quality education

* Provides leadership to department staff. Conducts staff recruitment, training and performance evaluations, according to Plan policies.

* Collaborates with external stakeholders, including physician partners and state leaders on quality improvement initiatives

Supervision Exercised:

* Supervises 5-7 clinical and non-clinical staff

* Supervision Received:

* General supervision is received weekly.

Qualifications:

Education:

* Bachelor's Degree in nursing, health administration or related field required.

Education Preferred/Desirable:

* Master's Degree in health related field preferred.

Experience:

* 10+ years progressively responsible experience in healthcare quality improvement and leading quality improvement programs

* 5+ years working in a managed care setting

* 5+ years working with Medicaid product, with proven track record of achieving high quality withhold/incentive performance

* 3+ years prior supervisory/managerial experience

Experience Preferred/Desirable:

* 3-5+ years clinical nursing experience preferred.

* Prior experience with NCQA accreditation highly preferred

* Vendor management experience preferred

* Data/analytics experience preferred

Certification or Conditions of Employment:

* Pre-employment background check

* CPHQ, Lean or green belt certification preferred

* Registered nurse with active license preferred

Competencies, Skills, and Attributes:

* Outstanding oral and written communication skills; ability to interact within all levels of the organization, influence change and lead cross-functional teams and initiatives

* Strong knowledge of CMS and state regulations and quality and process improvement methodologies

* Excellent analytical and problem-solving skills

* A strong working knowledge of Microsoft Office products.

* Detail oriented, excellent proof reading and editing skills.

* Highly motivated with the ability to work independently in a fast-paced environment with changing priorities

* Ability to work effectively in a fast-paced, dynamic environment

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees