Vice President of Quality and Clinical Program Oversight

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Provides leadership for all activities relating to the development and management of the Plan’s quality improvement and accreditation activities including NCQA, contractual and regulatory quality requirements and measures for all lines of business, HEDIS/Performance Improvement, clinical quality programs, Medical Policy, Utilization Management Program Management, clinical vendor management (excluding Pharmacy Benefit Manager). Develops and oversees strategies, policies and processes to ensure implementation of programmatic initiatives related to these areas with both internal and external stakeholders.

Our Investment in You:

· Full-time remote work

· Competitive salaries

· Excellent benefits

Key Functions/Responsibilities:
· Designs, implements and leads the Plan’s continuous quality improvement infrastructure. Acts as an internal consultant and resource to all levels of the organization relative to CQI processes and standards. Keeps abreast of strategic operating priorities and corporate goals to ensure processes, plans and policies are designed to fulfill strategic objectives.

· Additionally as part of Senior Leadership, participates in the company’s strategic planning and provides Executive Leadership with timely and accurate information.

· Leads all Plan activities for National Committee for Quality Assurance (NCQA) re-accreditation.

· Responsible for the ongoing administrative, clinical, fiscal and programmatic interaction with NCQA. Communicates with NCQA as needed to ensure the Plan is informed of all events and circumstances that affect the initial and on-going achievement of NCQA accreditation.

· Is responsible for overall Utilization Program Compliance as it pertains to accreditation obligations.

· Ensures compliance with contractual requirements relative to Quality Management / Quality Improvement.

· Oversees quality of care studies (based on targeted areas for quality management and quality improvement). This includes the following: analyzes data, performs root cause analysis, facilitates plans for improvement, provides technical support to Plan managers, and conducts re-measurement activities to assess performance improvement.

· Monitors quality performance indicators; prepares reports for quality oversight committees; develops vehicles to communicate performance to providers; and identifies clinical and administrative concerns for further investigation and analysis.

· Develops and manages communications with providers, government and accreditation organizations with respect to results of quality management studies, including oversight of remedial action as required.

· Directs the supervision of subordinate staff to include hiring, work allocation, scheduling, training and professional development, problem resolution, performance evaluation and related supervisory activities. Maintains budgetary responsibility for responsible departments.

· Serves as the Official Record Keeper of the Quality and Clinical Management Committee.

Supervision Exercised:
Directly manages 5-15 staff and indirectly oversees up to 40 staff.

Supervision Received:
General direction is received weekly


Bachelor’s degree in Health Care Administration, Public Health, Nursing, or related field or the equivalent combination of training and experience is required.

Master’s degree in related field strongly preferred.

10+ years progressively responsible experience in leading Quality Improvement Programs, which includes supervision of staff and budget management, is required.
Comprehensive knowledge of Medicaid regulations, guidelines and standards is required.
Comprehensive knowledge of accreditation organizations such as NCQA is required.

Experience within a managed care organization is strongly preferred.
Previous experience in designing and leading an accreditation process is strongly preferred.

Licensure, Certification or Conditions of Employment:
Active licensure as a Registered Nurse required
Pre-employment background check
CPHQ certification strongly preferred.

Competencies, Skills, and Attributes:
· Comprehensive knowledge of QM/QI standards, processes and metrics; including HEDIS, P4P, CAHPS, and CMS is required.

· Proven leadership skills and ability to build effective teams and direct the management of multiple, complex, high impact projects is required.

· Outstanding oral and written communication skills.

· Ability to build relationships and successfully interact with staff at all levels of the organization and with external constituencies.

Working Conditions and Physical Effort:
Regular and reliable attendance is an essential function of the position.
Work is normally performed in a typical interior/office work environment.
No or very limited physical effort required. No or very limited exposure to physical risk.

About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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