Director Quality Improvement- Health Plan

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family.  PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area.  PCHP works to fulfill of our mission by empowering members to live healthier lives.  By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job—it’s a passion to serve and improve lives every day.

Primary Purpose

Provides leadership oversight and directs the operations for the quality department and association functions. Accountable for ensuring compliance with regulatory agencies and accrediting bodies as well as Parkland Community Health Plan’s (PCHP) performance metric and rating programs.

Minimum Specifications

Education

• Bachelor’s degree in business administration, healthcare administration or related discipline required.
• Master’s degree in business administration, healthcare administration, or a performance improvement related discipline preferred.

Experience

• Five (5) years of experience working in a managed care organization or healthcare required.
• Experience with NCQA, CMS HHSC, or URAC required.
• Three (3) years of experience in compliance working with State level regulatory agencies in health care along with experience overseeing performance improvement projects in a managed care organization required.
• Eight (8) years of management experience required.

Equivalent Education and/or Experience

• Seven (7) years of experience in a comparable position working in Texas Medicaid or Medicaid Managed Care may be considered in lieu of a bachelor’s degree.

Skills or Special Abilities

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms.
• Demonstrated ability to coach and influence for results.
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization.
• Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals.
• Ability to work in challenging situations involving competing interests, and high level-interdisciplinary groups.
• Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Strong analytical and problem-solving skills.
• Knowledge of Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.
• Sound business acumen.
• Proficient Microsoft Office and computer skills.

Responsibilities

Operations

• Leads efforts to ensure the execution and development of department business plans and overseeing department operations with specific responsibilities for the overall management of NCQA accreditation, quality of care, HEDIS program activities, population health, data collection, and reporting, as well as member and provider satisfaction surveys, quality audits, and performance improvement efforts across the organization.
• Provides leadership and support in establishing and directing the Quality Program.
• Participation and overseeing of various committees and other task forces as may be established by management to plan, organize, and drive the plan’s goals.
• Provides overall direction by analyzing business objectives and customer needs; developing, communicating, building support for, and implementing strategies, plans, and practices; analyzing costs and forecasts and incorporating them into program plans; evaluating operational processes; measuring outcomes to ensure desired results; identifying and capitalizing on improvement opportunities; promoting a member-centric environment; and demonstrating adaptability and sponsoring continuous learning.
• Oversees the preparation for accreditation surveys.
• Elaboration and assessment of the overall Quality Improvement Program, Program Description, and work plan.
• Promote and implement a high-quality, patient-centered care approach by overseeing aspects of the Quality Improvement / Risk Management, Population Health, and Performance Improvement programs across the plan.
• Maintain in-depth knowledge of legal requirements related to management of employees, reducing legal risks, and maintaining compliance. Partner with the Legal Affairs department as necessary.

Strategy

• Responsible for developing and implementing strategies to deliver exceptional, reliable, evidence-based, equitable care across PCHP and promote a culture of continuous improvement.
• Coordinating the strategic planning for clinical quality processes, measurement, evaluation, and improvement, emphasizing using analytics/data, improvement science, and clinical standard work to improve outcomes and value.
• Identification of provider- and member-related intervention opportunities through analysis of HEDIS and CAHPS data; communication of HEDIS & CAHPS results to internal and external stakeholders, ongoing review of tools and strategies to improve processes for data collection and reporting; implementation of recommendations from EQRO and HHSC required activities.
• Works with provider network on developing and implementing strategies to improve health outcomes and patient satisfaction.
• Coordinates efforts, policies, and processes for NCQA Accreditation readiness, including gap analysis, tracking, and oversight of action plans for improvement.
• Conducts routine compliance audits identifying gaps and implementing remediation plans as necessary.

Quality

• Analyzes quality process and outcome data for emerging trends to make meaningful changes that result in improved patient outcomes.

• HEDIS Reporting Data/Analytics, including ongoing review of HEDIS technical specifications, supplemental data collection methods, chart retrieval measure calculation requirements, and reporting processes; medical record retrieval and abstraction, management and oversight of applicable vendor contracts, including but not limited to contracts for HEDIS software, EHR services, etc.
• Oversight of the completion and submission of the HEDIS ROADMAP, including required attachments and requested follow-up information, to the auditor; ensure the accuracy of abstracted medical record data and compliance with the Medical Record Review Validation (MRRV) component of the audit; submission of preliminary and final rates for auditor review using NCQA’s integrated Data Submission System (IDSS) tool; facilitate the implementation of any corrective actions required by the auditor.
• Leading special projects related to emerging risks and quality needs.
• Develops and/or maintains policies and procedures that support the initiatives that meet State and Federal legal requirements and standards.
• Collaborates with physicians to implement the clinical quality data initiatives as defined by PCHP.
• Facilitates, integrates, and/or coordinates the implementation and evaluation of quality improvement.
• Promotes understanding, communication and coordination of all quality improvement program components.
• Ensures adherence to all HHSC obligations as outlined in the Uniform Managed Care Manual, Uniform Managed Care Contract, and other relevant documents related to Quality Assessment and Performance Improvement, NCQA Accreditation, and HEDIS activities.

Regulatory

• Develop processes to maintain compliance with regulatory agencies and accrediting bodies.
• Works collaboratively with others to validate and sustain compliance with regulatory and accreditation standards.
• Works collaboratively with leadership and/or PCHP Compliance to investigate and respond to matters of concern or alleged violations taking corrective action as necessary.
• Provides timely and accurate responses to requests for information from regulatory agencies and accrediting bodies.
• Ensures organizational activities and operations are carried out in compliance with local, state, and federal regulations as well as laws governing business operations and requirements of accrediting agencies. Conduct periodic auditing for compliance.
• Fiscal Management and Operating Budget
• Operationally responsible for the financial performance of assigned area(s).
• Promote activities to achieve operational efficiency.
• Manage the approved budget through frequent and regular monitoring. Implement written action plans to address variances adjusting strategies as necessary to meet budgetary targets.
• Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs.
• Manage staffing levels within established targets.

Talent Management

• Responsible for managing and supporting the assessment of individual and department performance needs to maximize workforce performance.
• Assist leaders with developing the appropriate standards of performance and defining accountability for their respective areas.
• Provide guidance and support leaders with the performance appraisal process.
• Work collaboratively with leaders to implement performance management strategies to address uncorrected performance deficiencies of employees.
• Promote and support a culturally welcoming, inclusive, collaborative, and highly engaged work environment where everyone feels empowered to bring their full, authentic selves to
• Ensure Human Resource metrics (i.e., retention, vacancy, engagement) meet established targets. Utilize workforce metrics to monitor, identify, and respond to workforce trends.
• Timely completion of employee performance appraisals.
• Conduct regular meetings, inform team of changes in policy or procedure, and provide information regarding overall strategy and direction of the health plan.
• Mentor, coach, and support direct reports with building teamwork, professional development, and education to achieve optimal performance and develop talent.
• Ensure employee engagement survey participation rates and results meet established targets.
• Mandatory requirements are completed timely by employees.
• Required licensure, certification, and/or registry are current and in good standing for all employees.
• Employee performance is monitored and managed. Consult with the Office of Talent Management as appropriate regarding employee performance concerns and disciplinary action.

Professional Accountability

• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicate ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times.
• Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

Job Accountabilities

1. Identifies and analyzes the design of jobs, work processes, workflows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
4. Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
5. Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of PCHP.
6. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.