Director, Quality Improvement - Registered Nurse (RN) - Columbia, SC at Columbia

Job Description

About WellCare: WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled, as well as prescription drug plans. The company serves approximately 2.7 million members nationwide as of Dec. 31, 2012. The company employs more than 4,500 nationwide. For more information about WellCare, please visit the companys website at www.wellcare.com. A Fortune 500 company traded on the New York Stock Exchange (symbol: WCG).

EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.

The Director, Quality Improvement plans, develops, and directs the Quality Improvement functions, provides leadership necessary to achieve national best practice performance levels in quality improvement initiatives, ensures that the quality of healthcare services rendered meets or exceeds professionally recognized community standards, interfaces with a diverse range of clinical and administrative professionals, resolves sometimes-complex policy and service issues within the group and directs data analytic and reporting activities that are prescribed by customers and regulators in a multi-market environment, and ensures compliance with state, federal and accreditation requirements.

Department: Health Services / Quality Improvement
Reports to: VP, Quality Improvement
Position Location: Columbia, SC 29210

Essential Functions:

• Develops and implements the quality improvement (QI) Program in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards.
• Facilitates strategic and tactical planning for the quality improvement program, including needs assessments, evaluations, root cause analysis and interventions.
• Develops and implements systems, policies, and procedures for the identification, collection, and analysis of performance measurement data to facilitate identification of improvement opportunities.
• Analyzes, updates, and modifies standard operating procedures and processes to continually improve QI Department services/operations.
• Implements procedures to promote network-wide patient safety and care continuity and coordination practices.
• Oversees the annual HEDIS data collection process, ensuring that all opportunities to increase key performance rates have been explored and acted on.
• Collects and summarizes regional market performance data/information, identifies opportunities for improvement, recommends performance improvement actions that reflect nationally-recognized best practices as applicable, presents findings to the appropriate QI committee, and acts on approved actions.
• Conducts oversight and interfaces internally and externally with various stakeholders of the member incentive and provider pay for performance programs, and prepares evaluative/outcome data and resulting recommended program modifications as may be appropriate.
• Directs development of presentation content and sequencing of agenda topics to ensure that relevant material is presented to appropriate QI committees.
• Participates in, facilitates, and/or leads QI committees such as the QI Committee, the Utilization/Medical Advisory Committee, topic-focused internal quality improvement teams, etc.
• Collaborates with Health Services, Operations, and Information Technology departments to ensure full integration of quality improvement reporting for contract and accreditation compliance.
• Develops systems for close coordination of QI related functions with departments whose activities are directly a part of the QI Program, including Credentialing.
• Establishes professional relationships with state, stakeholders, and community agencies to facilitate quality process internally and externally.
• Coordinates and completes all QI activities required to meet national accreditation and regulatory performance improvement initiatives.
• Communicates new state, federal, third party regulations and accreditation requirements to the staff.
• Participates in site visit preparation and execution by regulatory and accreditation agencies (state agencies, URAC as may be required by specific state, NCQA, CMS, EQRO).
• Directs staff in the implementation of performance initiatives to drive HEDIS performance and contract compliance quality performance.
• Is responsible for monitoring and evaluating staff performance.
• Performs other duties as assigned.

Job Requirements

Education: A Bachelors Degree HealthCare, Nursing, Health Administration or equivalent experience required; a Masters Degree in Healthcare or Public Health preferred

Experience:

• 10+ years of quality improvement experience
• 5+ years managed care experience
• Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards
• Medicaid and Medicare experience
• 3-5 years management/leadership experience

Licenses/Certifications:

• Licensed Registered Nurse (RN) with active licensure strongly preferred
• Certification in Healthcare Quality by the Healthcare Quality Certification Board, or equivalent preferred

Special Skills (e.g. 2nd language):

• Strong understanding of accreditation, federal and state regulations/requirements
• Excellent verbal and written communication skills
• Strong analytical and problem solving skills
• Ability to communicate effectively with people with varying levels of education
• Ability to multitask in a fast paced environment

Technical Skills/Requirements: Proficient in Microsoft Office such as Excel, Word, Visio, PowerPoint and Outlook.


Country: USA, State: South Carolina, City: Columbia, Company: WellCare Health Plans Inc..