Director of Quality and Accreditation

The Director Quality and Accreditation is responsible for the Continuous Quality Improvement (CQI) and Quality Management (QM) strategy for HSCSN. This includes HSCSN’s Quality Assessment and Performance Improvement (QAPI) Program, related QM activities under The District’s Child and Adolescent Supplemental Security Income Program (CASSIP) and organization-wide Quality Management initiatives. The Director/Sr. Director leads the multidisciplinary teams to achieve annual objectives and goals for planned clinical and non-clinical programs, initiatives, and measurement activities, including evaluation of the effectiveness of these activities, champions QM principles and processes to HSCSN associates and external stakeholders to support optimal health outcomes and satisfaction for enrollees.


Minimum Education
Bachelor’s Degree in health care field (Required)
Master’s Degree MSN, MPA, or MBA (Preferred)

Minimum Work Experience
8 years of current progressive experience in management and quality improvement (required) in Health plan/MCO setting (preferred)

Required Skills/Knowledge
Previous Accreditation experience is required.
Previous HEDIS reporting experience preferred.
Strong professional base in areas of QI.
Experience in interpreting raw data and conducting comparative analysis.
Knowledge of CQI methodologies.
Proficient in the use of personal computer including spreadsheet analysis, presentation graphics, and word processing.
Highly developed oral, written and organizational skills.
Ability to communicate effectively with individuals and groups and agencies.
Ability to manage multiple priorities and make appropriate decisions to assure the completion of tasks on time.
Flexibility and willingness to undertake new responsibilities as assigned.
Appropriate professional demeanor to represent HSC to internal and external constituents.
Ability to work under stress.
Ability to solve problems of a complex nature.
Ability to multitask.

Required Licenses and Certifications
Clinical professional licenses ( e.g., RN or SW) is preferred, licensed in the District of Columbia, if applicable.
Certifications in quality management or related disciplines (preferred)

Job Functions
Essential job duties:

Plans, organizes, and directs the plans QI/PI program to bring it into 100% compliance with CASSIP contract and other relevant legal/regulatory standards and meets demographic and epidemiological needs of the population served.
Establishes annual QI/PI objectives and annual goals in conjunction with senior leadership and facilities development of annual quality work plan and annual program evaluation and submits documents to MAA in accordance with CASSIP contract.
Educates the organization on the essentials of Continuous Performance/Quality Improvement: team dynamics, cultural change, performance improvement, quality leadership, tools, and techniques.
Develops, designs, and conducts QI/PI (re)orientation program for all staff.
Serves as consultant to HSCSN Medical Staff, Executive and Management Staff regarding customer service and performance improvement issues and development of departmental performance measurement and improvement activities in support of system wide initiatives.
Researches and establishes key performance indicators and benchmarks for all HSCSN services and operations.
Reviews and updates performance measures at least annually or more frequently to keep pace with changing HSCSN needs/activities.
Analyzes and trends quality data and develops aggregate and individual quality reports as indicated.
Coordinates and oversees identification, collection, and reporting of QI/PI measurement data. Coordinates on a quarterly basis the reporting of all quality initiatives to all appropriate committees, including the Board of Directors.
Directs staff to coordinate POIC and Quality Council of Network Providers meetings.
Facilitates HEDIS reporting and coordinates the quality improvement action plans for those measures that do not meet MAA benchmarks.
Acts as Advisor/Facilitator for Performance Improvement Team and is effective utilizing the PDCA model. Keeps all meetings on schedule and productive and updates the Leaders as necessary.
Ensures the tracking of all customers concerns/complaints are related corresponds. Identifies trends, and researches and recommends process improvement to prevent reoccurrence to management team and reports results to POIC team.
Directs staff to evaluate the network system for the consistent review of network provider’s performance and compliance with quality measures and makes recommendations for oversight of delegated services/providers.
Coordinates the research, identification and implementation of provider standards of care and clinical practice guidelines in conjunction with Medical Director and Quality Council.
Coordinates all CASSIP related corrective action plans and QSOPs; monitors monthly deliverables associated with corrective action plans.
Coordinates annual Delmara survey and Mercer study and works with leadership team to develop corrective action plan; monitors compliance of implementation.
Develops, secures approval of and administers a budget, (including a capital budget), that provides for the attainment of agreed upon goals and objectives in accordance with approved plans, and providing efficient and cost effective utilization of resources.
Effectively recruits hires, assigns work to, schedules, develops and evaluates staff.
Ensures that all performance appraisals in area(s) of responsibility are completed accurately, thoroughly, fairly and in support of organizational philosophy and goals, and are submitted by due date.
Initiates, authorizes and/or recommends or delegates authority as appropriate for salary changes, promotions, transfers, discipline, termination, vacation schedules, leave of absence, performance appraisals and other personnel actions in coordination with HR and in accordance with established hospital policy.
Accomplishes, or has agreed upon progress towards, more than 80% of planned goals and tactics, as well as goals developed during the evaluation period.
Attends mandatory in services and meetings or arranges with the appropriate supervisor for satisfactory compliance.
Maintains current knowledge in present areas of responsibility (i.e. attends ongoing educational programs).

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