Additional Information: Occasional travel is required for this position.
- With oversight from Director responsible for strategic planning, development, implementation and monitoring of the quality portion of the Quality Improvement/Utilization Management Program and Work Plan and Pay for Performance Programs
- Initiate within all Gateway Health PlanSM Departments, collaborative activities based on sound data analysis to promote the development, implementation, monitoring and evaluation of quality related programs and services.
- Ensure the standards of the National Committee for Quality Assurance (NCQA) and all applicable State and Federal Regulatory Agencies are appropriately integrated into the Quality Improvement/Utilization Management Program.
- With oversight from the Director, accountable for the program management and ongoing implementation of DPW's MCO Pay for Performance Program, the Gateway Provider Pay for Performance Program and other assigned Quality Improvement initiatives.
- Build and execute the business plans (strategic and operational) for various programs and initiatives; gain approval and assure ongoing program and initiative implementation to support the achievement of goals and objectives. Analyze the effectiveness of the business plan and make recommendations for program changes.
- Manage QI staff and resources. Assign staff to support cross-departmental project teams. Assure project teams are operating effectively and are completing work within required timeframes. Conduct performance reviews and ongoing staff development. Develop and manage department budget.
- Degree in clinical or human services
- Four (4) years of experience in Quality Improvement/Management
- Two (2) years previous supervisory or team lead experience
- Four (4) years leadership experience in NCQA survey preparation
- For Nurse Applicants, a Pennsylvania RN License or Eligible for Pennsylvania RN Licensure by Endorsement
- Four (4) years combined experience in Quality Improvement, Utilization Management, Disease Management, Preventive Health or Case Management in a managed care health plan environment
- Four (4) years managed care health plan experience in Medicaid / Medicare
- Understanding of health care diseases or conditions, their management, health care delivery systems and processes
- Certification in Quality Management Principles
Highmark Inc. - 19 months ago
Highmark has staked its claim as the largest health insurer in the Keystone state. A licensee of the Blue Cross and Blue Shield Association,...