Director, Quality of Care and Accreditation

Position Title: Director, Quality of Care and Accreditation
Department: Network and Clinical Support
Title of Manager: Vice President, Network Relations and Quality Improvement
Supervises: Quality of Care & Accreditation Staff
Exemption Status: Exempt
Requisition ID: 21107

General Statement of Duties

This position is responsible for developing framework and overseeing the execution of quality assurance as it relates to contractual quality assurance and performance improvement (QAPI), relevant accreditation standards, and provider credentialing for all CareOregon lines of business. Work is focused on business group oversight, as well as enterprise-wide engagement. Primary duties include operational planning and oversight, as well as resource, relationship, and people management. This position provides input into strategic plans for the department and the organization.

Education and/or Experience

Minimum 10 years’ experience in health care quality programs, compliance, risk management or other related experience
Minimum 3 years’ experience with Medicare or Medicaid programs
Minimum 4 years’ experience in a supervisory position
Health plan quality-related experience

Essential Position Functions

Technical/Operational Leadership
Evaluates, monitors, and leads CareOregon’s credentialing and QAPI activities, objectives, and analysis, including the overall CareOregon QAPI Program Description, Work Plan, and Annual Evaluation.
Develops initiatives and program frameworks that provide clear direction on the governance, ownership, and execution of key QAPI program deliverables (specifically TQS, MOC, QAPI Description and Annual Evaluation, accreditation programs).
Leads the development, execution, and ongoing maintenance of systems and strategies to provide assurance to governing boards that CareOregon is meeting contractual QAPI standards and any relevant accreditation standards in administration of physical, oral, and behavioral health, pharmacy, and NEMT benefits.
Ensures compliance with and drives the development and implementation of policies and procedures that are compliant with Medicaid/Medicare QAPI regulations and, as appropriate, are aligned with applicable accreditation requirements.
Leads consistency of quality assurance and improvement approach and linkages between CareOregon lines of business, departments, benefits, and committees.
In partnership with Regulatory Affairs, reviews and supports development and submission of QAPI reporting requirements to CMS and OHA to ensure accuracy, completeness and alignment with quality strategies; works with Legal Affairs to redact reports, as necessary, to protect trade secrets, PHI, or other legal interests.
Builds a framework for external partnerships and non-clinical programs in the department to ensure they are well-integrated throughout the organization, as appropriate to fulfill or optimize CareOregon’s quality assurance obligations.
Identifies alignment opportunities between quality of care standards, operational quality assurance activities, and clinical quality improvement objectives, as identified and prioritized by clinical leaders of CareOregon and its network partners.
Helps develop and promotes communities of practice for QAPI work embedded in other departments.
Keeps the Compliance Officer informed about any quality issues which may present compliance-related risk to the organization.
In partnership with CareOregon and CCO executive leaders, ensures the CareOregon Board of Directors, CCO Boards and ICN Advisory Committee are appropriately informed about quality performance; provides support to any Quality-related committees of the Boards, as requested.
Provides strategic leadership and partnership to lines of business to implement operational and clinical initiatives that assure that CareOregon meets all quality work plan goals, performance improvement programs, and regulatory deliverables, and any applicable accreditation standards.

Strategic/Operational Planning
Participates in the development of vision, goals, and strategic plans for quality assurance teams.
Develops short and long term plans and policies; oversees the development and execution of standard operating procedures.
Provides input into the organization’s strategic plans.
Maintains a business unit view while establishing department priorities, being cognizant of broader business unit and organizational impacts.
Financial/Resource Management
Recommends department budget in alignment with short and long term plans.
Manages department resources to ensure priorities are accomplished.
Approves resource allocations within budget, including people, finances, and timelines; make decisions on exceptions.

Relationship Management
Leads effective communication system for work group(s), ensuring a collaborative culture.
Builds and ensures effective relationships across internal teams and external organizations for current or future integration.
Partners with internal leaders and managers in identifying improvement plans and processes.
Represents CareOregon in external meetings and functions, providing productive leadership presence and effectiveness.
As directed by CareOregon or CCO executive leaders, acts as delegate in relevant state and national committees and ensures programs and policies consider the evolving quality landscape.

Employee Supervision
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.

Essential Department and Organizational Functions
Supports and operates in alignment with the organization’s core values.
Strives to meet work goals that contribute to departmental and organizational goals.
Adheres to organizational standards, policies and procedures, as well as compliance requirements.
Performs other duties as assigned.

Knowledge, Skills and Abilities Required
Expert knowledge of principles, practices, procedures and professional standards associated with quality assurance program management, utilization review and techniques for evaluation of program effectiveness
Thorough understanding of Medicare/Medicaid rules and regulations
Excellent verbal and written communication skills including the ability to persuade, influence, negotiate and make formal presentations
Ability to lead multi-stakeholder meetings and collaboration
Ability to effectively convey business unit goals and plans ensuring integration into strategic plans and initiatives
Ability to balance strategic and operational thinking
Ability to develop and manage team members, including hiring, goal setting, coaching, performance management, and development
Ability to plan, organize, manage, and monitor work projects
Ability to analyze and solve problems, prioritize and organize and manage multiple tasks
High degree of initiative and motivation
Ability to work in an environment with diverse individuals and groups
Basic computer skills, including spreadsheet and word processing

Physical Skills and Abilities Required
Lifting/Carrying up to 0 Pounds
Pushing/Pulling up to 0 Pounds
Pinching/Retrieving Small Objects
Reaching Above Shoulders
Climbing Stairs
Repetitive Finger/Wrist/Elbow/
Shoulder/Neck Movement
0 hours/day
0 hours/day
0 hours/day
0 hours/day
0 hours/day
0 hours/day
3-6 hours/day
Speaking Clearly
0 hours/day
0 hours/day
0 hours/day
0 hours/day
More than 6 hours/day
More than 6 hours/day
More than 6 hours/day
3-6 hours/day

Cognitive and Other Skills and Abilities Required
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.

Working Conditions
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
☐ Other_________________________________________
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
Hazards: n/a
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.

Position Description »