Director of Quality

SUMMARY:

The Director of Quality is responsible for the operations of PHN’s value-based care programs requiring coordination across clinical, quality, reporting and contracting teams to ensure effective implementation, compliance and contractual arrangements fulfill regulatory requirements, communication and monitoring for success of designated programs.

Leads and manages PHN Quality Team for the execution and continuous monitoring of services designed to improve clinical quality performance and reduce unnecessary health care spending by: a) ensuring Medicare Advantage and commercial pay for performance and shared savings plan requirements and opportunities are met, b) producing relevant and useful information in cooperation with CMO and PHN physician practices, c) creating a strong value proposition for PHN membership by increasing rewards related to performance, d) enhancing the level of integration technology across the network and e) constantly improving upon a common quality focused culture.

Reports to the PHN Executive Director while working closely with the PHN Chief Medical Officer. Assists the PHN CMO and Executive Director with strategic planning, business development and annual budget management related to CI operations.

QUALIFICATIONS:

EDUCATION AND EXPERIENCE:

· Bachelor of Science in Nursing (BSN) from an accredited nursing program

· Master of Science in Nursing (MSN) or Master’s Degree in Business, public health or healthcare administration preferred or an additional 3 years work experience in a healthcare system or health insurance company management position

· Current licensure with valid Registered Nurse (RN) license in Georgia is required

· A minimum of 4 years directly related experience working for either a health plan/payer system or a comprehensive IPA or PHO operating as a clinically integrated network

KNOWLEDGE, SKILLS AND ABILITIES:

· Excellent interpersonal skills with proficiency in team building and conflict resolution across multiple hospital departments, physicians’ practices, health plans and community organizations

· Demonstrated leadership in various patient care settings that include developing clinical policies and procedures

· Experience in gathering and analyzing HEDIS, STARs and aggregate population health data

· Experience in applying scalable, disciplined, and coordinated operational, strategical, and technological approaches to improve the health of attributed populations.

· In depth knowledge of HEDIS and STARS program measures, Patient Centered Medical Home program, Meaningful Use, pay for performance, shared savings management, hospital systems, health plans and the overall managed healthcare industry

· Strong understanding of Medicare, Medicaid and commercial pay for performance and shared savings incentive programs

· Excellent analytical, strategic planning, quality management and project management skills

· Strong organizational and time management skills required to schedule, meet and maintain critical deadlines and routine reporting demands

· Excellent written and verbal communication skills

· Proficient in Microsoft Suite software products and project management software

· Must possess a high degree of confidentiality, ethical standards, respect for the chain of command and professional presentation

FUNCTIONS & SPECIFIC AREAS OF RESPONSBILITY:

· Lead and manage PHN Quality Team to set and accomplish all pay for performance, shared savings, and data analytics goals

· Lead regular PHN staff meetings to identify work priorities and manage work progress and completion

· Establish staff performance criteria and conduct annual staff performance evaluations

· Report to CMO and Executive Director on data analytics/IT program performance, payer relationships, value-based program performance and other assigned projects

· Maintain a detailed understanding of all shared savings and pay for performance contracted programs for providers to maximize incentive payments

· In collaboration with health plans, develop and recommend strategy modifications (as needed) to the CMO and Executive Director for the most effective means to improve clinical performance, reduce unnecessary spend and consequently earn greater rewards money

· Responsible for ensuring PHN conducts multiple meaningful, specific and value-added performance Improvement education events for providers and practice staff

· Manage the sharing of clinical performance data with the appropriate constituencies, CMO, PHN providers, practice management staff, PHN Committees and PHN leadership

· Assist the Chief Medical Officer and Quality/Rewards Distribution Committee in developing quality performance and rewards policies. Maintain P4P distribution database to ensure payments made accurately and timely.

· Assist the Chief Medical Officer in ensuring PHN physicians comply with the quality performance standards required for PHN membership and managing the enforcement of provider corrective action plans (CAPs) and performance improvement plans (PIPs) approved by the PHN Quality Committee for providers out of compliance

· Assist Executive Director and Chief Medical Officer in developing PHN’s annual goals presented to the PHN Board for review and approval

· Help build strong relationships and facilitate productive communication between PHN providers, Executive Director, Chief Medical Officer and PHN staff.

· Facilitate a positive work environment for employees through team building, coaching, innovation, constructive feedback, work delegation, personal example and goal setting that encourages creativity, open dialogue on work issues, professional growth and a consistent high level of performance

· Encourage and support employee decision-making within the scope of their responsibilities

· Assist Executive Director in:

o developing and presenting for PHN Board approval, general policies related to PHN business functions and CI operations

o negotiating current, relevant and viable value-based rewards contracts as supplements to standard Medicare Advantage, Medicaid and commercial fee for service contracts

o preparing PHN’s annual budget for PHN Executive Committee and Board approval

o managing PHN expenses within annual budget parameters

o completing special assignments as requested

Job Type: Full-time

Pay: $130,000.00 - $140,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Experience:

• Healthcare System or Health Insurance Company Management: 3 years (Preferred)

Ability to Commute:

• Augusta, GA 30901 (Required)

Ability to Relocate:

• Augusta, GA 30901: Relocate before starting work (Required)

Work Location: Hybrid remote in Augusta, GA 30901

Salary : $130,000 - $140,000