Director, Medicaid/CHIP Quality Program
The Director of Medicaid/CHIP Quality will provide direct strategic planning, monitoring, oversight, and subject matter expertise surrounding the quality rating success in UPMC’s Medicaid (Physical Health) and Children’s Health Insurance Program (CHIP) lines of business. Based on review of data and related industry evolution in quality strategies and measure specifications, the Director strategically develops, implements, and evaluates member, provider, data and community-focused interventions and programs that support the success of the health plan’s Medicaid quality ratings for NCQA STARs and alignment with the Pennsylvania Department of Human Services’ (DHS) Managed Care Organization (MCO) Pay for Performance (P4P).
This key PA DHS-facing role leads efforts supporting NCQA accreditation, PAPM reporting, EPSDT programs, and other regulatory compliance functions. The role is responsible for quality reporting, performance improvement plans, and other improvement activities to meet state regulatory requirements for applicable products, ensuring accuracy and timeliness. The Director leads matrix collaboration and oversight of Medicaid/CHIP product quality results, integrated operational and clinical teams, and related quality analysis/reporting. This role drives an innovative and proactive quality strategy with a focus on alignment and prioritization across multiple products and quality improvement teams. The Director works collaboratively with peer Directors in the Quality Improvement Department to prioritize, align, and lead performance improvement activities that contribute to overall success of UPMC Health Plan quality programs.
- Maintain and improve Medical Assistance/Medicaid (MA – Physical health/CHIP) product quality ratings, including NCQA STARs HEDIS/CAHPS measures and MCO Pay for Performance measures, through strategic planning and partnerships with MA/CHIP Product business owners, operations, and clinical leadership.
- Advance the process associated with the launch and efficacy of cross-functional workgroups and project teams through Quality Planning & Monitoring Committee to optimize multi-prong interventions across membership, provider network, communities of need, and the data environment to assure all aspects of the HEDIS, CAHPS (member satisfaction/experience) and other Medicaid metrics improve year over year.
- Lead the reporting of routine progress across all intervention tactics, efficacy of such tactics, overall rating results, and strategy for improvement to the Quality Strategy Committee, inclusive of Medicaid/CHIP clinical and senior leadership teams. Collaborate with leadership to align key priorities and assure effective execution through the organization-wide Quality Action Plan with clear deliverables and ownership.
- Partner with subject matter experts in Clinical Services (Physical Health/ Behavioral Health/Population Health), Pharmacy, Member Services, Network Contracting, Marketing, Business Process & Performance Improvement, and other areas to develop aligned strategies, analyses, and recommendations for improvement. Identify opportunities and support collaborations with other departments, the UPMC health system, and the provider network that improve quality of care delivery, member experience, and outcomes.
- Support NCQA accreditation readiness (Health Plan/Health Equity) by supporting the ongoing training, competency assessment, mock audits, monitoring of metrics and corrective action in collaboration with the Director of Quality Improvement who oversees all NCQA accreditation standards and related survey readiness.
- Ensure timely delivery of contractually mandated, regulatory requirements, including the development and submission of annual quality program description, work plan and evaluations, and associated monthly, quarterly, and annual reporting.
- Supervise applicable quality improvement staff responsible for regulatory components of the quality program, such as development, execution and reporting of Performance Improvement Projects (PIPs) and External Quality Review (EQR) preparation, procedures, and performance audits.
- Direct process improvement and corrective action plans in response to performance/quality deficits in surveys, accreditations, EQRs, state audits and other state mandated reporting.
- Build a high performing team across strategically targeted growth areas that will deliver quality health outcomes and cost effectiveness. Develop process to regularly receive ideas on innovation and new methods of improving performance.
- Review best practices, industry results/learnings, and industry products routinely for new reporting, analysis, and modeling opportunities. Integrate with health plan leaders to collaborate in member/provider incentive decisions and other programmatic interventions where applicable.
- Advance reporting of Medicaid/CHIP population performance and utilization of social determinate data in the evolving health equity strategy and related improvement tactics to reduce health disparities. Proactively analyze and implement actions related to network expansion efforts as it relates to Medicaid products.
- Advance the Health Plan’s Health Equity strategy development and related interventions as applicable the Medicaid population, in collaboration with others in Quality Improvement leadership, the Center for Social Impact, Community Relations, and Provider Relations. Support Health Equity Accreditation activities in collaboration with Quality Analytics and the Quality Regulatory/Clinical teams.
- Support the pediatric improvement strategy, population health management strategy, Medicaid/CHIP leadership, and Clinical Services to ensure Medicaid/CHIP measures have actionable, effective, member-centric tactics to drive improved quality rating performance. Contribute to the advancement of innovative approaches to drive member engagement and a positive member experience.
- Support team development, training, and/or mentoring curricula on the fundamentals of improvement science, matrix collaboration, and effective improvement frameworks (e.g., PDSA, Lean, Six Sigma, Agile). Leverage process improvement tools and techniques to drive innovative thinking and data-driven, rapid-cycle approach to quality improvement.
- Produce dashboards, trend, and surveillance reports for senior management and department leaders and teams. Support system enhancements that support gap closure automation such as EMR feeds and electronic extraction. Conduct data analysis including demographics, disparities, and social determinants to determine new quality improvement strategies. In collaboration with Marketing and respective clinical leaders, explore enhanced messaging techniques and technology for members and providers related to HEDIS measures.
- Bachelor’s Degree in healthcare administration, nursing, hospital administration, business, public health, or related field.
- RN or PA licensed in state of Pennsylvania preferred.
- Masters preferred, or comparable work experience considered.
- 6-8 years of relevant management experience; managed care preferred.
- Quality professional, Certified Professional in Health Care Quality (CPHQ) preferred.
- Demonstrated experience with NCQA/CMS quality improvement regulatory requirements.
- Excellent communication skills, including verbal, written, and interpersonal.
- Above-average analytical and problem-solving skills.
- Strong leadership skills and independent decision-making ability while driving team empowerment and organization-wide collaboration.
- Computer skills in Word, Excel, PowerPoint, and Outlook required.
Licensure, Certifications, and Clearances:
- RN or PA licensed in state of Pennsylvania preferred.
UPMC is an Equal Opportunity Employer/Disability/Veteran.
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