Medical Director, Quality

Job Summary

The Medical Director, Quality works collaboratively with the Chief Quality and Population Health Executive and is a key position on the Health Services team. This position implements strategy for the quality improvement functions within the health plan, in collaboration with the administrative and clinical leaders of the organization.

The Medical Director provides clinical leadership and oversight ensuring high-quality, cost-effective, evidence-based care. This includes supporting clinical and population health improvement efforts, tracking and presentation of results of improvement efforts and ongoing measures of clinical processes; and overseeing regulatory readiness.

The position is responsible for directing network performance improvement programs and establishing new improvement activities, including methods to track peer review, credentialing, and provider performance improvement plans, site surveys, and potential clinical quality and critical events reviews.

This position is responsive to the needs of the Chief Quality and Population Health Executive and the Board of Governors subcommittees for Compliance & Quality. This position leads and acts as an advisor to Credentialing and Peer Review Committee, Provider Quality Review and Clinical and Member Advisory Groups, and serves as liaison to various provider focused departments such as Credentialing and Provider Network Management in establishing and maintaining best practice operations for provider quality in efforts to ensure excellent member experience and access to care.

Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals. 

Duties

Support quality improvement efforts for the organization and promote an organizational culture of quality improvement and performance.

Develop, approve, and update medical policies, procedures, and standards of care based on current evidence-based practices.

Oversee provider facing activities relevant to Healthcare Effectiveness Data and Information Set (HEDIS), Centers for Medicare and Medicaid Services (CMS) Stars, Covered CA performance, National Committee for Quality Assurance (NCQA), and state/federal regulatory bodies, including managing provider performance measurement and reporting.

Oversee and review the delivery of patient care to ensure it meets quality standards and regulatory guidelines.

Responsible for directing peer review activities including chairing the Credentialing and Peer Review Committee and managing the Potential Quality Issues process. 

Maintain and enforce compliance with all federal and state laws, accreditation processes and standards (such as NCQA), and other regulatory requirements. Guide quality assurance and performance improvement programs and participate in quality review committees.

Support population health management and practice transformation efforts to improve quality and value of care, control total costs of care, elevate member experience of care, and advance health equity.

Work with senior leadership in deploying standardized evidence-based best practices in medicine and clinical content and ensure adoption of best practices.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 10 years of extensive post-medical degree experience in clinical practice, quality improvement, and population health management.

Proven experience in a physician leadership role, including managing teams.

Preferred:

Minimum of 5 years of clinical experience with direct patient care.

At least 5 years of experience with credentialing, peer review, or provider performance improvement.

Informatics and Analytic experience with quality data from multiple disparate sources, including but not limited to 834, 837, 278 EDI and HIE HL7.

Skills

Required:

Must have a passion to improve quality for vulnerable populations.

Strong leadership presence with the ability to lead, mentor, and motivate a team.

Ability to think strategically and take a broad, business-oriented perspective.

Strong analytical and problem-solving skills, with a data-driven approach to evaluating programs.

Exceptional communication and presentation skills to effectively convey complex medical concepts to diverse audiences.

Ability to review and assess clinical cases for potential quality issues and legal cases for assessment of severity and actions necessary.

Must maintain current competency in provider quality regulations and standards.

Capacity to work in a fast-paced, dynamic, and often ambiguous environment.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information