Director, Quality Management Jobs

POSITION SUMMARY/RESPONSIBILITIES
Responsible for the development, implementation, evaluation, management and oversight of the health plan's quality performance and improvement monitoring activities. Coordinates and oversees these activities through collaborative relationships with other departments and services. Coordinates and oversees Community First Health Plans, Inc. (Community First) procedures for resolution of appeals of adverse determination and external review for appeals. Interfaces with state and federal regulators, the State External Quality Review Organization (EQRO), and other health plans as a representative of Community First.

EDUCATION/EXPERIENCE
Bachelor’s degree in Nursing or health-related field is required. Master’s degree in a health-related field is preferred. Thorough knowledge of health care regulations (Centers for Medicare and Medicaid Services and Texas Department of Health and Human Services), various accreditation standards (in particular, NCQA and HEDIS), policy formulation, quality management, and process improvement is required. Knowledge of analytical and investigative techniques sufficient to identify current methodologies and conduct evaluations of the effectiveness of the results is required. At least five years of supervisory experience in a managed care setting with exposure to multiple product lines is required. Certification by a national accrediting body in health care quality preferred. Strong project management skills and data management skills are required.

LICENSURE/CERTIFICATION
Must be licensed as a Registered Nurse in the State of Texas.