Associate Vice President, Quality and Clinical Compliance
The Associate Vice President, Quality and Clinical Compliance is responsible for the development, implementation and oversight of the Corporate Quality Improvement Program with focus on Medicare Advantage lines of business. In collaboration with Senior Management, serves as the quality leader, subject matter expert, and facilitator by assisting all departments to identify clinical and administrative opportunities for improvement of service to members and customers, with accountability for improvement in outcomes. Achieves and maintains accreditation by appropriate accreditation agencies.
- Designs and implements programs and initiatives to maximize the Plans' Centers for Medicare & Medicaid Services (CMS) Performance Measures ("Stars").
- Manages Plans' HEDIS, CAHPS and HOS processes to timely and accurate submission.
- Responsible for assuring accreditation by a CMS-approved accreditation agency, such as NCQA or URAC. Collaborates with the Chief Quality Officer, Vice President of Health Services, Chief Medical Officer and Vice President of Compliance to address regulatory and clinical compliance issues.
- Supports accreditation of Insurance and Specialty Divisions.
- Directs successful completion of Quality Improvement plans and documents, including but not limited to annual Quality Improvement Program Description, Quality Improvement Work Plan, and Work Plan Evaluation.
- Supports Plan Quality Improvement Committee and its reports to Board Level Quality Management Committee.
- Participates in the development and evaluation of company and departmental policies and procedures.
- Develops educational programs for internal and external customers on quality, measurement, and accreditation requirements.
- Selects, trains, supervises, and evaluates the staff.
- Develops and manages to budget that supports department activities.
Skills, Experience, and Qualifications:
- Current RN license
- BSN required; MSN preferred
- 5 years clinical experience
- 3 years Medicare Managed Care experience in a quality leadership position including staff management
- Commanding knowledge of Centers for Medicare and Medicaid Services Medicare Advantage regulatory requirements, NCQA, HEDIS, HOS, and CAHPS
- Experience leading successful health plan accreditation process