Vice President, Quality and Risk Adjustment

Seeking a Quality SME to oversee all related activities for the Quality Improvement functions. Lead and direct process improvement activities for more efficient and streamlined workflow. Oversee the business processes related to risk adjustment and quality improvement for assigned products and plans.
 

• Responsible for all activities related to National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance ensuring highest level of accreditation
• Manage all aspects of HEDIS improvement activities, including outreach, incentives, data integrity and chart review
• Review and implement new technological tools and processes and foster team concept with internal and external constituencies
• Present results of improvement efforts and ongoing performance measures and recommend actions plans to senior management
• Research and incorporate quality improvement best practices into operations
• Organize and control activities, methods, and procedures to achieve business objectives
• Formulate and establish policies, operating procedures, and goals in compliance with internal and external guidelines
• Manage and ensure compliance of EPSDT program as well as compliance and turnaround time of grievances and appeals

Qualifications:

• Bachelor's degree in Nursing or related clinical field or equivalent experience. Master's’ degree preferred. 
• 10+ years of healthcare operations experience, including quality improvement and NCQA accreditation experience. 
• Experience managing acquisition and integration of external data sources. 
• Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff. 
•  Familiarity with running Risk Adjustment prospective and retrospective programs preferred