Senior Director of Quality Improvement & Utilization Management
Job Title: Sr. Director of QI & UM
Location: Honolulu, HI
Job Description: AlohaCare has retained Morgan Consulting Resources, Inc. to conduct the search for their Senior Director of Quality Improvement & Utilization Management. We are seeking either a Registered Nurse or Medical Doctor for this Honolulu-based role. This is a wonderful opportunity to join a mission-driven organization with a very strong and cohesive senior leadership team.
About the organization:
AlohaCare is a local, non-profit health plan founded in 1994 by community health centers. They work with Hawaii’s most vulnerable populations to provide Medicaid and Medicare coverage to more than 70,000 members. The organization serves Hawaii’s Medicaid population through a QUEST Integration contract with the State of Hawaii and operates a Medicare Special Needs Plan (SNP). AlohaCare’s service area is statewide, which includes the islands of Oahu, Kauai, Maui, Molokai, Lanai and the Big Island.
AlohaCare’s Vision, Mission and Values:
Vision: We envision empowered, healthy communities living in the spirit of aloha.
Mission: 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.
Core Values: Fairness, Honesty, Loyalty, Respect/Dignity, and Trust.
For more information about AlohaCare, please visit their website at https://www.alohacare.org/.
About the Senior Director position:
Reporting to the Chief Medical Officer, the Senior Director of Quality Improvement & Utilization Management provides strategic leadership for AlohaCare’s Quality and Performance Improvement Program (QAPI) and Utilization Management Program (UMP) in alignment with AlohaCare’s mission and strategic priorities for the MedQUEST Medicaid and Medicare Special Needs Plan lines of business. The Senior 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 Senior 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 Senior 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 ideal candidate must be relationship driven and motivated to develop strong ties to the provider community. The Senior Director will approach the job with a high level of collaboration and patience and be an active listener with excellent communication skills. S/he will be a champion of the organization’s mission both internally and externally. We are seeking individuals who want to embrace the many benefits of living in Hawaii and thrive in a community-focused culture.
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:
- Quality Improvement projects, HEDIS, STARS, CAHPS, HOS and other quality measure collection, Quality P4P for providers, Population Health, NCQA accreditation, Appeals & Grievances, Quality of Care investigations, prior authorization & concurrent review (physical & behavioral health), clinical eligibility for special services – disability (ADRC), LTSS (1147 LOC), SMI (CCS), etc.
- 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
- Works with the CMO and Medical Directors to ensure availability of clinical guidance and support for clinical review staff
- Defines and implements the Utilization Management Program (UMP) to ensure members receive care in the least restrictive setting through consistent application of appropriate clinical criteria (e.g., InterQual)
- Continually evaluates cost effectiveness of care and monitors over and underutilization of services
- Minimum ten years of work experience in Quality Improvement/Quality Assurance/Utilization Management for a managed care organization and/or provider organization with formal delegation for these functions is required
- Must be a physician or registered nurse licensed in the State of Hawaii or have the ability to obtain license
- 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
- Managing and overseeing health services operations including Directors, 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 utilization management
- 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
- Advanced degree
- Certified Professional in Healthcare Quality (CPHQ) strongly preferred
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.
If you or someone you know has the qualifications for this role, I’d love to set up a time to talk. Thank you so much for your time.
Lisa Coyne, Principal
Morgan Consulting Resources, Inc.
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