Care Management & Quality Director

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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.

2. 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.

3. The Director oversees clinically integrated programs for capitation members, leads operational and outcome improvement initiatives, and ensures clinical oversight for all member outreach and engagement programs.

4. This individual plays a key role in deploying resources to support measurable improvements in health outcomes, member experience, and cost efficiency.

5. The position shares responsibility for developing and executing an annual population health improvement plan, incorporating clinical strategy to assess intervention effectiveness, identify strategic opportunities, and design targeted solutions that support accreditation and compliance objectives.

6. Develop and evolve the population health strategy framework for member/patient management and engagement across the continuum of care, recommending interventional strategies as well as operational efficiencies to produce measurable outcomes.

7. Identify customer KPI’s and manage program operations to deliver customer defined results.

8. Provide leadership, direction, guidance, clinical expertise, and consultation to the population health program staff to support Peak and provider owner objectives.

9. Support culture change and transformation activities with the clinical team.

10. Analyze population performance and advise on best actions for improvement.

11. Advise on and participate in company strategy and product roadmap, providing clinical insight and requirements on market changes and client needs.

12. Develop and maintain knowledge of contract(s) with customers, as well as working relationship(s) to foster collaboration in data sharing, care coordination, population health management, and outcome improvement.

13. Develops strategic direction for Star Rating improvement through ongoing execution and program standardization for Clinical HEDIS stars measures.

14. Collaborates and facilitates activities with other units at Corporate and within Peak Health plans for intervention development and execution to support Medicare Stars measure level improvement and program revenue maximization across all key categories of the Stars Program.

15. Sets direction for Stars program activities with department leadership including leading corporate Stars initiative that require timely follow-up, tracking and communication on an on-going basis.

16. Serves as a subject matter expert and represents the Clinical department in meetings and discussions Related to the Clinical HEDIS pod for Stars management.

17. Develops strategic direction for Star Rating improvement through ongoing execution and program standardization for Clinical HEDIS stars measures.

18. Collaborates and facilitates activities with other units at Corporate and within Peak Health plans for intervention development and execution to support Medicare Stars measure level improvement and program revenue maximization across all key categories of the Stars Program.

19. Develops strategic direction for Star Rating improvement through ongoing execution and program standardization for Clinical HEDIS stars measures.

20. Clinical leadership and regulatory expertise.

21. Process optimization and operational discipline.

22. Analytical problem solving and quality improvement.

23. Cultural competency and empathy.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to stand and walk short distances for eight or more hours.

2. Frequent bending, stooping, or stretching.

3. Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Hybrid work environment (subject to Peak Health policy).

2. Occasional travel across West Virginia and regional service areas for meetings, audits, trainings, and provider collaboration.

SKILLS AND ABILITIES:

1. Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, NCQA accreditation standards, disease management, population health management, care management and discharge planning.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, case management and discharge planning.

3. Excellent written and oral communication.

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

5. Attention to detail.

6. Proficiency with Microsoft Office products.

7. Ability to work under stressful working conditions.

8. Meeting defined deadlines and deliverables is an imperative skill for this role.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2403 PEAK Medical Management

Address:

1085 Van Voorhis RdMorgantownWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.