Medicaid Quality Management Health Plan Director

Location: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Medicaid Quality Management Health Plan Director will be responsible for driving the development, coordination, communication, and implementation of a strategic clinical quality management and improvement program within assigned health plan. Responsible for working with the regional head of quality management to direct the clinical quality initiatives, including HEDIS and CAHPS quality improvement, NCQA accreditation and compliance with regulatory agencies and other objectives. 

How will you make an impact: 

• Works with both internal and external customers to promote understanding of quality management activities and objectives within the company and to prioritize departmental projects according to corporate, regional, and departmental goals.

• Maintains expert knowledge of current industry standards, quality improvement activities, and strong medical management skills.

• Serves as a resource for the design and evaluation of process improvement plans/quality improvement plans and ensures they meet Continuous Quality Improvement (CQI) methodology and state contractual requirements.

• Collaborates with other leaders in developing, monitoring, and evaluating Healthcare Effectiveness Data Information Set (HEDIS) improvement action plans, year round medical record review, and over read processes.

• Monitors and reports quality measures per state, Centers for Medicare and Medicaid Services (CMS), and accrediting requirements.

Minimum Requirements:

• Requires BA/BS in a clinical or health care field (i.e. nursing, epidemiology, health sciences) and a minimum 5 years progressively responsible  experience in a health care environment or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Strong BH quality management experience to include oversight of state-specific Quality Improvement Projects (QIPs), STARS, and HEDIS performance metrics strongly preferred.

• Certified Professional in Healthcare Quality (CPHQ) from the National Association for Healthcare Quality, or Healthcare Quality and Management (HCQM) certification from the American Board of Quality Assurance and Utilization Review Physicians strongly preferred.

• Demonstrated expertise with NCQA accreditation (including behavioral health and health equity standards), survey readiness, and ongoing compliance activities strongly preferred.

• Extensive experience leading large-scale, cross-functional initiatives involving data integration, reporting infrastructure, and partnership with IT and analytics teams (e.g., HIE or similar data exchange efforts) strongly preferred.

• Proven ability to lead in a highly matrixed environments as well as partnering with clinical, network, analytics, and external stakeholders while facilitating governance forums and driving accountability across teams strongly preferred.

• Experience managing state-regulated contracts with high reporting volume strongly preferred.

• Deep familiarity with clinical workflows, member safety events, and behavioral health care delivery models strongly preferred.