Director of Quality

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The Company:
AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:
AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

The Opportunity:
The Director of Quality provides strategic leadership for AlohaCare’s Quality and Performance Improvement Program (QAPI) in alignment with AlohaCare’s mission and strategic priorities for the MedQUEST Medicaid and Medicare Special Needs Plan lines of business. The Director’s primary responsibility is operating a management infrastructure that promotes member safety, quality of care, positive gains in population health, and assures cost effective access to care in the safest, least restrictive setting. To achieve these goals, the Director must ensure efficient processes that address NCQA standards, achieve contractual compliance and document outcomes via standard metrics. This role requires commitment to cross-functional collaboration and to community partnerships that drive quality improvements. The Director is accountable for creating a culture that is member-centered, integrated, collaborative, inter-disciplinary, data-driven, transparent, innovative, team-oriented, training committed, and sound in managed care fundamentals. The Director is mindful and committed to the AlohaCare Care Model. He/She reports to the Chief Medical Officer.

Primary Duties and Responsibilities:
• Directs multiple operational areas, demonstrating an understanding of utilization management and quality of care across the continuum of services for members. Key operational areas may include:
o Quality improvement projects
o HEDIS, STARS, CAHPS, HOS and other quality measure collection
o Quality P4P for providers
o Population health
o NCQA accreditation
o Appeals & grievances
o Quality of care investigations
o Credentialing
• Developing and implementing AlohaCare’s QAPI, Quality & Performance Improvement Program Description, QI Work Plan, and Performance Improvement Projects (PIP)
• Improving AlohaCare’s Star Ratings and MedQUEST quality outcomes through innovative approaches in engaging members and providers
• Directs strategic initiatives in population health, including disease management and EPSDT, integrated in AlohaCare’s Care Model
• Responsible for timely, accurate and consistent credentialing processes to ensure the provision of quality services for our members, as well as meet other organizational needs;
• Works with the CMO and Medical Directors to ensure availability of clinical guidance and for clinical staff
• Works collaboratively with other leaders within the Health Services Division, as well as throughout the rest of the company, in order to achieve contractual expectations, quality initiatives, and excellent service
• Submits annual plans for departments or programs that include goals, metrics, ownership, timelines, and budgets, ensuring an alignment with organizational priorities and making adjustments to plan as needed
• Maintains competency in defining and addressing expense and revenue issues, capital expenditures, and budgeting, regarding their impact on MLR (Medical Loss Ratio)
• Applies Dashboards consisting of Key Performance Indicators and non-KPI metrics, interpreting trends and significant variances as opportunities to improve outcomes
• Incorporates actionable analytics, utilizing business intelligence tools, care coordination tools, and claims systems (QNXT) in order to identify issues, mitigate risks, and develop solutions
• Ensures compliance with Medicare (Special Needs Plans) and MedQUEST program requirements, as well as NCQA accreditation standards and HIPAA, demonstrating proactive leadership
• Is knowledgeable about all lines of business, products, and cohorts of members from a clinical perspective, as well as the special challenges in rural Hawaii and neighbor islands
• Serves on standing committees of governance and management; minimally, the following:
o Staff for the AlohaCare Board of Directors Committee on Quality
o Vice-chair and principal staff, Corporate Quality Improvement Committee (CQIC)
o Member, Corporate Compliance Committee
o Staff, Practitioners Advisory Committee
o Staff, Credentialing Committee
• Develops a team that collaborates, communicates, and coordinates within the department and with other departments throughout the organization; Develops his/her Managers in leadership and management capability, building on their individual talents and passion to serve the AlohaCare’s mission
• As an Executive Council member, provides input for strategic direction for the entire organization
• Develops and maintains external relationships with MedQUEST, CMS Medicare, and other major stakeholders, local and national, as well as with ACAP (Association of Community Affiliated Plans)
• Demonstrates leadership attributes such as active listening, defining issues, resolving conflict, being facilitative, inspiring staff, empowering staff, and training the trainers
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality -employees have access to AlohaCare data based on the data classification assigned to this job title

Required Qualifications:
• Five to seven years of work experience in Quality Improvement/Quality Assurance for a managed care organization and/or provider organization with formal delegation for these functions is required
• Minimum five years of experience in Medicaid and/or Medicare programs
• Minimum five years of experience in management and supervision
• Clinical program development and implementation experience
• Valid driver’s license and access to vehicle for offsite tasks

Required Skills:
• Managing and overseeing health services operations including Managers, Supervisors and Staff
• Demonstrated track record of participation in audits and compliance programs
• Sound understanding and skills in managed care processes and tools for quality improvement and credentialing
• Sound data analysis skills and detailed knowledge of managed care outcomes measures
• Capable of developing effective working relationships with staff at all levels in the organization, and with network providers, committee members, and members of the AlohaCare Board of Directors
• Ability to work with mathematical concepts such as probability and statistical inference, and ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations
• Able to communicate effectively both verbally and in writing, including presentation skills

Preferred Qualifications:
• Physician or registered nurse licensed in the State of Hawaii
• Advanced degree
• Certified Professional in Healthcare Quality (CPHQ) strongly preferred

Mental, Physical and Environmental Demands:
• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.
• Inside working conditions
• No environmental hazards
• Requires operation of general office equipment to include PC

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.

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