Director, Quality Compliance

The Director of Quality Compliance is accountable for defining strategic direction of the Quality Compliance program through development, implementation, monitoring, and evaluation of Strive Health’s accreditation, delegation, and Documentation Management programs The Director leads a team of associates which support all Quality Compliance activities. The Director utilizes expertise in NCQA accreditation, health plan delegation, and policy management to improve the Quality Program and support patient care. The Director, along with the Quality leadership team, works to improve patient outcomes, experience, and safety through Quality improvement initiatives. The Director leads regular mock audits and partners closely with legal and regulatory affairs to ensure that strive maintains continuous readiness for audits and accreditation requirements. The Director reports to the VP, Quality and is able to ensure day-to-day processes are conducted in accordance with NCQA Standards and other internal and regulatory standards.

Essential Functions

Leadership

• Provides strategic and day-to-day guidance, leadership, and development to the Quality Compliance team to ensure all components of accreditation, delegation, and documentation management meet expectations of internal and external partners.
• Creates strategies to develop a continuous readiness program for NCQA accreditations and delegated activities.
• Partners with the markets and clinical teams across all verticals of business to ensure policy and process is maintained in accordance with established standards. Effectively communicates gaps and recommendations for improvements.
• Develops and maintains reporting and analyses for clinical program effectiveness, in partnership with the Director of Quality Improvement and the Sr. Manager of Patient Experience.
• Acts as advisor to market and business on appropriate documentation and qualitative and quantitative analyses for required improvement opportunities and assuring business owners are acting on their opportunities for improvement.
• Perform a variety of complex work in planning, coordinating, amending and managing continuous readiness activities, utilizing a strong understanding of the business processes related to corporate/market operations and accreditation standards.

Accreditation

• Holds deep knowledge and experience as the SME for NCQA Health Plan requirements and standards, and stand-alone CM and PHP accreditations.
• Working knowledge of Credentialing NCQA requirements for delegation.
• Expert with program management for mock audit NCQA readiness
• Expert in the NCQA submission process

Delegation

• Provides guidance and oversight of the delegated services and reporting.
• Works with the contracting team to ensure all pre-delegation requirements and delegation agreements align with Strive services. Is the point of contact for new implementations.
• Supports the Sr. Associate, Delegation in the day-to-day delegation requirements from payor partners.
• Serves as the Senior leader point of contact for delegation escalation issues

Documentation Management

• Demonstrates expertise in policy requirements and management.
• Educates and recommends policy and process changes to meet accreditation requirements.
• Chairs the Policy Review Committee
• Leads, with support from the Associate, Accreditation and Delegation, the Policy Review Committee

Minimum Qualifications

• Bachelor's Degree in related fields or an equivalent combination of education and experience.
• 8+ years' related experience (quality, compliance, etc.)
• 6+ years’ experience in Health Plan, CM, and/or DM NCQA and/or other Quality accreditation work. Actively managed a minimum of three full cycles of an accreditation submission.
• 6+ years’ experience with client management
• 5+ years’ experience with delegation oversight, preferably in a managed care setting

Preferred Qualifications

• Bachelor’s Degree in Nursing or other health-related field required; Graduate degree in related field or equivalent combination of education and experience preferred
• Complex Case Management auditing
• Certified Case Manager
• Strong clinical assessment and critical thinking skills
• Excellent verbal and written communication skills
• Ability to work in a team environment.
• Flexibility and strong organizational skills needed.
• Proficiency in Microsoft Office, Adobe Acrobat and internet/web navigation.
• Care Management Certification
• Will substitute 5 or more years of clinical experience along with an associate degree and RN licensure in place of the bachelor’s degree and RN licensure.
• NCQA Case Management and Population Health accreditation standards and process experience
• Knowledge of the organization of medical records, medical terminology, and disease process
• Remote experience preferred.

Annual Salary Range: $130,000.00-$163,000.00