Director, Quality Assurance – Operations
Position Title: Director, Quality Assurance – Operations
Department: Clinical Operations
Title of Manager: Vice President, Clinical Operations
Supervises: Supervises: Quality Assurance/Clinical Operations Managers
Exemption Status: Exempt
Requisition ID: 21106
This position is responsible for leading the execution of operations quality assurance strategy and activities. Areas of oversight include authorizations, appeals and grievances, claims, and enrollment functions within the operations division. This role works closely with division leadership to define quality standards, targets and KPIs, and to promote and support a culture of quality and compliance across the enterprise. This role is also responsible for communicating results, process improvements and remediation outcomes. Primary duties include technical and operational leadership, as well as resource, relationship, and people management. This position provides input into strategic plans and goals for the broader organization.
Education and/or Experience
Minimum 10 years’ experience in health operations, including a minimum of 8 years’ experience with utilization review/management, appeals/grievances, quality assurance, process improvement, program development, implementation, and evaluation
Minimum of 3 years’ experience using criteria, such as InterQual or similar products for utilization management or appeals/grievance reviews, preferably spanning both physical and behavioral health
Minimum 4 years’ experience in a supervisory position
Minimum 8 years’ experience in managed care or health insurance industry
Directs quality assurance activities across the organization in support all CareOregon lines of business; areas of responsibility include oversight of clinical and non-clinical teams serving CareOregon members and contracted providers performing quality assurance audits and appeals and grievances.
Leads the execution of operations quality assurance initiatives, plans, and goals in a matrixed environment in alignment with organizational vision and goals.
Ensures compliance with federal and state regulatory and contractual requirements.
Develops, or directs the development and maintenance of, documented policies and procedures to ensure accurate, efficient, and compliant operations.
Collaborates with the Senior Medical Director on updates to clinical policies and procedures; consults with Medical Director(s) as appropriate for input on complex clinical cases and benefit management policies.
Ensures quality targets are established, met, and reported.
Effectively uses root cause analysis and data analytics to report improvement opportunities; collaborates with business partners on developing mitigation plans for prevention and operational excellence.
Develops measurement systems and dashboards to effectively monitor operations quality and identify process improvement opportunities across multiple functions and teams.
May serve as a sponsor or chair for key projects and initiatives.
Remains current with industry trends, best practices, and approaches to drive quality, efficient and compliant operations.
Identifies, establishes, and manages vendor contracted services as applicable.
Identifies opportunities for automation, analytics, and vendor services to support meeting and exceeding production and quality targets.
Develops, oversees, and reports outcomes of an internal quality review program.
Develops and presents proposals, updates and results to executive leadership.
Instills work culture of continuous process improvement, innovation, and quality.
Participates in the development of vision, goals, and strategic plans.
Provides input into the strategic plans of the organization.
Develops short and long-term plans and policies; oversees the development and execution of standard operating procedures for ensuring quality.
Maintains a business unit view while establishing department priorities, being cognizant of broader business unit and organizational impacts.
Recommends budgets in alignment with short and long-term plans.
Manages resources to ensure priorities are accomplished.
Ensures approval for budget variances as required.
Approves resource allocations within budget, including people, finances, and timelines; make decisions on exceptions.
Leads effective communication for work group(s), ensuring a collaborative culture.
Builds and ensures effective relationships across internal teams and external organizations including contracted provider network and state and federal regulatory agencies.
Works cross-functionality with internal and external stakeholders in identifying and driving projects, process improvement initiatives, and operational efficiencies.
Works closely with senior leadership, peers, and cross-department leadership providing programmatic, organizational, and technical support to ensure effective collaboration and integration of clinical and operations functions.
Works closely with the Senior Medical Director to assure that activities meet clinical and operational quality standards.
May represent CareOregon in external meetings and functions with regulators, members, and providers.
Directs team(s) and establishes team direction and goals in alignment with the organizational mission, vision, and values.
Identifies work and staffing models; recruits, hires, and oversees a team to meet work needs, using an equity, diversity, and inclusion lens.
Identifies department priorities; ensures employees have information and resources to meet job expectations.
Leads the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff.
Manages, coaches, motivates, and guides employees; promotes employee development.
Incorporates guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, and decision making.
Ensures team adheres to department and organizational standards, policies, and procedures.
Evaluates employee performance and provides regular feedback to support success; recognizes strong performance and addresses performance gaps and accountability (corrective action).
Performs supervisory tasks in collaboration with Human Resources as needed.
Perform work in alignment with the organization’s mission, vision, and values.
Support the organization’s commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals.
Strive to meet annual business goals in support the organization’s strategic goals.
Adhere to the organization’s policies, procedures, and other relevant compliance needs.
Perform other duties as needed.
Knowledge, Skills and Abilities Required
Extensive knowledge of billing and coding in various healthcare settings including inpatient, outpatient, SNF, and DME
Detailed knowledge of the Division of Medical Assistance Programs (DMAP) and Centers for Medicare and Medicaid Services (CMS) regulations
Knowledgeable of CPT and HCPCS coding and ICD-10
Detailed knowledge and experience with utilization review/management tools, Oregon Medicaid benefits, and commercial software products used in benefit management
Knowledgeable in Medicare/Medicaid rules and requirements, as well as Oregon state regulations
Proficient developing KPI metrics reporting for operations quality using spreadsheets, BI tools, pivot tables, graphs, and charts
Knowledge of managed care and health plan concepts, principles, practices and operations.
Ability to influence others without direct authority and negotiate favorable outcomes
Ability to take complex ideas and processes and communicate them in a clear and concise manner
Understanding of clinical and health plan operations within a managed health care or health insurance business model
Understanding of financial structures, fiscal responsibility, and the economic impact of business decisions
Ability to balance strategic and operational priorities, and proactively identify and resolve operational barriers and issues
Skilled in budget and resource plan development and management
Ability to communicate effectively, both verbally and in writing; strong presentation skills
Ability to effectively convey business unit goals and plans ensuring integration into strategic plans and initiatives
Ability to direct teams of clinical and non-clinical operations support staff engaged in diverse activities
Team management skills, including hiring, goal setting, coaching, performance management, and development
Ability to create and develop strategic partnerships with multiple stakeholders both internally and externally
Ability to work with internal and external stakeholders regarding technology, process, and regulatory issues
Physical Skills and Abilities Required
Lifting/Carrying up to 10 Pounds
Pushing/Pulling up to 0 Pounds
Pinching/Retrieving Small Objects
More than 6 hours/day
More than 6 hours/day
More than 6 hours/day
More than 6 hours/day
More than 6 hours/day
Cognitive and Other Skills and Abilities
Ability to focus on and comprehend information, learn new skills and abilities, assess a situation, and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.
Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):
☒ Inside/office ☐ Clinics/health facilities ☐ Member homes
Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.
Equipment: General office equipment
Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment
Veterans are strongly encouraged to apply.
Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.