Director, Care Management & Quality - Peak Health

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Come join Peak Health – a fast growing provider led health plan. This role will be responsible for the people, process and business requirements necessary to appropriately manage care, lead the plan’s HEDIS/Stars program, and deliver exceptional customer service. Reporting to the Health Plan President, The Director, Care Management and Quality will be an integral member of the health plan’s senior leadership team.

The Director of Care Management & Quality leads the development and implementation of clinical intervention strategies tailored to the needs of commercial, Medicare, and other populations supported by Peak Health as needed. This role collaborates across care teams to identify optimal clinical support and programming, including integration of the clinical strategy to ensure alignment with organizational goals and population health priorities. This individual plays a key role in deploying resources to support measurable improvements in health outcomes, member experience, and cost efficiency. The position shares responsibility for designing and leading population health strategies in conjunction with provider owner partner resources and incorporating clinical strategy to assess intervention effectiveness, identify strategic opportunities, and design targeted solutions that support accreditation and compliance objectives.

This role also oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs supporting HEDIS and Medicare Star Ratings improvement. Responsible for planning, developing, and directing the implementation of improvement strategies to ensure high level of performance across Medicare Stars programs. Leads enterprise partnership discussions and improvement opportunities across matrix teams and provider owners. This role is responsible for ensuring maintenance of programs for members in accordance with prescribed quality standards and provides direction and implementation of key Stars strategies to support program regulations.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Healthcare Administration, Public Health, or related field.

EXPERIENCE:

1. Five (5) years of prior management experience in Care Management and/or Quality in a managed care setting.

2. Eight (8) years of experience working in Care Management or Quality.

3. Three (3) years of experience in population health, healthcare, HEDIS, HOS, CAHPS, STARS or QRS.

4. Five (5) years of Managed care experience across a broad portfolio of products or provider managed care setting, specifically with state and federal health programs.

5. Five (5) years of experience with care management principles, population health management, CMS guidelines, regulations, NCQA® and HEDIS® standards/guidelines.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

2. Licensed Physician Assistant or Licensed Nurse Practitioner.

3. Master of Science in Nursing (MSN).

EXPERIENCE:

1. Care Management and/or Quality for Medicare and/or Medicaid populations. 

2. Leading care management or population health management program development to address the health of a managed care population.

3. Five (5) plus years of clinical experience, with at least 2 years in care management, case management, or population health.

3. HEDIS quality measurement knowledge or experience.

4. Leading and collaborating with others on National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance.

5. Excellent communication, coaching, and organizational skills.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. The Director of Care Management & Quality delivers value to customers by leading the development and implementation of clinical intervention strategies tailored to the needs of defined populations.