Director, Clinical & Service Quality
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Wilmington, DE 19806
Gateway Health Plan
Job Description :
I. GENERAL OVERVIEW:
The Director, Clinical Outcomes will focus on ensuring enterprise-wide compliance with clinical and service quality requirements for mandatory quality accreditation and federal and multi-state regulations. Primary responsibility is to directly lead, professional consultant staff in the development, implementation and on-going monitoring and follow through for the Health Plan’s clinical and service quality programs and initiatives to ensure Highmark is compliant with all applicable external accrediting and regulatory requirements (NCQA, CMS, DOH, URAC, etc.), as applicable in all service regions. This includes leading a team of clinical and non-clinical professionals to work with various departments across the corporation and to direct multidisciplinary quality committees comprised of internal staff and/or external network providers to ensure interventions are fully developed and implemented to complete the annual requirements for the National Committee for Quality Assurance (NCQA), URAC Health Utilization Management, Centers for Medicare and Medicaid Services (for Medicare Advantage and new healthcare insurance exchange product compliance), Federal Employees Program (FEP), Pennsylvania Department of Health and Department of Insurance for the CHIP Product. This also includes leading professional staff in ensuring corporate compliance with member services and provider accessibility requirements, member and practitioner/ practice adherence patterns and compliance activities for all regions of operation to identify barriers that are unique to each area and to direct the development of specific targeted interventions to ensure continued improvement of clinical and service quality. The Director will lead the consultant team to identify and address regulatory and compliance risk throughout Highmark departments across its service regions. The position requires strong on-going knowledge of the dynamic external accrediting and regulatory requirements and compliance with intricate and detailed specifications.
II. ESSENTIAL RESPONSIBILITIES:
1. Directs and is accountable for professional staff, both clinical and nonclinical, which is responsible for ensuring clinical and service -related compliance of the corporation. This includes quantitative and qualitative analysis to identify improvement opportunities and implementing interventions to improve member care and service. Activities apply to the Delaware, National, Pennsylvania and West Virginia markets and all Highmark health insurance products and impact Highmark compliance with regulatory and accreditation requirements for health plans.
2. Directs and is accountable for professionals who lead multidisciplinary groups of individuals throughout the enterprise to develop interventions and direct provider-based and internal Highmark committees to advance member health and service outcomes. This involves action plan development, timelines, large-scale complex multi-pronged interventions, and communication strategies for complex issues with large impact on the organization and its members. These activities impact Highmark’s market standing and sales efforts and include the corporate expectation of continual improvement Highmark ratings across all lines of business and in all service regions.
3. Directs the professional team members in their advisory roles to departments across the corporation in order to revise and enhance enterprise-wide interventions to affect positive changes in Health Plan customer service and member health care. This requires up-to-date knowledge of current and upcoming trends in health and customer service opportunities and the ability to correctly identify root cause barriers and develop cost-effective interventions across the Highmark service area to improve care/service. Leads and directs area within QMPM to develop the knowledge used to drive changes.
4. Directs and leads professional staff in the development, adoption, and continued maintenance of nationally-endorsed preventive health and clinical practice guidelines that are utilized by Highmark network providers as guidance for providing care to their patients who are Highmark members. Additionally, the preventive health guidelines form the basis for the corporate-wide Highmark preventive health schedule of benefit coverage for members and apply to all applicable Highmark health insurance products across all Highmark service regions. The ongoing Guideline process requires frequent interaction by the professional staff with various corporate representation at the manager and director levels, including, but not limited to: Benefits Coding, Sales, Product, Actuary, Utilization Management, and the Law Department. Represents Highmark interests with national organizations and national projects to develop and implement such guidelines. Responsible for maintaining information and company history regarding guideline decisions.
5. Directs and leads professional staff that ensures corporate compliance with accreditation and regulatory standards for continuity and coordination of medical care and behavioral health care activities. This includes development and implementation of clinical research, analysis, identification of improvement opportunities and implementation of interventions. Responsible for maintaining information and corporate history regarding the analysis and ongoing activities in place to meet compliance. Applies to Delaware, Pennsylvania and West Virginia markets. Impacts Highmark’s compliance with NCQA, Medicare Advantage, Pennsylvania Department of Health, West Virginia Insurance Commissioner’s Office and Delaware Insurance Department requirements.
6. Directs and leads professional staff that maintains accessibility activities to ensure members have appropriate and timely access to care and services across all health insurance products. This includes development and implementation of research, analysis, identification of improvement opportunities and implementation of interventions. Applies to Delaware, Pennsylvania and West Virginia markets. Impacts Highmark’s compliance with NCQA, Medicare Advantage, Pennsylvania Department of Health, West Virginia Insurance Commissioner’s Office and Delaware Insurance Department requirements.
7. Directs and leads professional staff that ensures member satisfaction/dissatisfaction activities, including overseeing administration of the annual CAHPS® member satisfaction and Behavioral Health satisfaction surveys conducted through an NCQA-certified external vendor, including selection of the vendor, contract execution and administration. Activities includes development and implementation of studies/data collection, monitoring of enterprise-wide satisfaction/dissatisfaction data, identification of improvement opportunities and coordination with departments throughout Highmark for implementation of interventions that are corporate-wide in nature and affect multiple departments. Additional responsibilities of the staff include accountability for coordination of activities with Healthcare Management Services, performance report analysis, annual compliance audits, and documentation maintenance. Applies to Delaware, Pennsylvania and West Virginia.
8. Represents QMPM on the newly formed collaborative of Highmark/Carnegie Mellon University/ Allegheny Health Network’s The Disruptive Health Technology Institute with the review and selection of proposals. Corporate business and clinical knowledge is critical for the proper and thorough vetting of research proposals. These efforts directly impact the distribution of Highmark funding for projects and/or future research.
9. Directs and leads professional staff that ensures compliance with the Blue Cross Blue Shield Associat