Sr. Director, Clinical Quality

Your Role

Reporting to the VP, Quality, the role of the Sr Director is critical to the success of Blue Shield of California and the Clinical Quality department in realizing its goals and objectives.  This individual will play a key role as part of the Quality team in delivering and collaborating on all aspects of quality outcomes.  Responsible for the performance of all quality rating systems and for the development of strategic plans and programs to support continuous quality improvement. Developing, assessing, and delivering partnering on interventions, policies, and procedures at all levels and with critical operational departments to ensure quality programs will meet or exceed guidelines or requirements.

Your Work

In this role, you will:

• Working with the VP, Quality, build out a detailed strategy to execute on multi-year quality plans which may include unique strategies for ACO, HMO, PPO and Medi-Cal delivery models. The quality plans will include staffing needs, infrastructure development, and partnering with other parts of the organization
• Manage a team of direct reports including several critical leaders and teams which deliver critical quality programs, models and operations
• Act as thought leader within BSC on methods to change member health behaviors and physician practice style that impact and improve quality outcomes
• Represent BSC on Quality at conferences and in statewide and national initiatives, and with state and federal regulators as necessary
• Evaluate and evolve current quality improvement and pay for performance programs using technology, member engagement strategies, partnerships with providers, incentives and other methods
• Partner with other BSC teams to enhance and customize programs to populations of members and providers
• Implement quality programs regional network specific strategy by working with internal and external organizations to disseminate and improve quality initiative uptake
• Develop and oversee provider incentive programs. Evaluate success of the programs and adjusting annually to drive outcomes. 
• Oversee Medical Record Review and abstraction strategy and process
• Evaluate and Report Performance on Quality and Member Experience. Conduct program evaluations to inform revisions and refinements to interventions
• Ensure regulatory compliance and oversee audits

Your Knowledge and Experience

• Minimum of 10 years of relevant experience required including 8 years of management experience
• Bachelor’s degree required in Nursing, Public Health, or other related field
• Master's degree in relevant field preferred
• Requires in-depth knowledge of quality, and change management processes
• Prior experience with total quality management, continuous quality improvement, and six sigma or lean methodology
• In-depth knowledge of NCQA, HEDIS process and specifications
• Ability to deliver a multi-year quality strategy