Clinical & Nursing
Senior Director, Clinical Quality and Medical Management
Albuquerque, NM, United States

It’s Time For A Change…

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely—70.3% in year-over-year revenue growth in 2017. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

Who You’ll Be Working With:

You will be working as a part of the Medical Management Team leadership and closely with other health plan departmental leaders, Health Plan Analytics, and Chief Operating Officer (COO), reporting to the Chief Medical Officer (CMO). You will provide leadership across all Population Health Management, Wellness, and Quality areas for the organization.

 

What You’ll Be Doing:

The Senior Director of Clinical Quality and Medical Management drives programmatic approaches to clinical quality, population health, wellness, and overall member engagement in care. This position also oversees the successful, ongoing quality accreditation of the health plan by relevant accrediting bodies such as the Office of the Superintendent of Insurance, the Centers for Medicare & Medicaid Services (CMS), and the National Committee for Quality Assurance (NCQA). The Senior Director works with the CMO and Senior Medical Director to implement and provide oversight of medical management procedures with selected third-party administrator (TPA) vendors. This position also:

  • Ensures the development of staffing and training plans for population health and quality, as well as overseeing the organizational strategy for these programs along with the CMO and Senior Medical Director.
  • Defines and directs strategy related to wellness and population health initiatives for health plan members (e.g., gaps in care closure programs, CMS-required, or otherwise desired chronic condition programs, and third-party wellness relationships and programs).
  • Establishes contracts and manages relationships and processes with third-party vendors for the annual Enrollee Satisfaction Survey (ESS), the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, and Healthcare Effectiveness Data and Information Set (HEDIS®)/Quality Rating System (QRS) production.
  • Directs and oversees the NCQA accreditation readiness and review process for the organization.
  • Assists in the implementation of integrated care delivery strategies for regionally identified teams of providers.
  • Works closely with behavioral health management/consultants to develop and implement strategies for integrated care management of members with behavioral health conditions.
  • Works with Company leadership and directors to develop programs for identifying provider and member issues related to medical management and quality programs, and identify solutions for ongoing operations.
  • Identifies and implements other strategies that ensure quality care, access to care, and the financial success of the Company.
  • Participates in outreach to care managers and other clinical team-based caregivers to ensure highly coordinated care processes for health plan members.
  • Participates in appropriate meetings at the federal, state, and local levels to share information and identify best practices.
  • Participates with Sales in broker and group sales outreach related to development and implementation of group wellness offerings.
  • Participates with medical directors and Provider Services in provider group outreach related to provider group case management programs as supported.
  • Other duties as assigned.

 

The Experience You’ll Need (Required):

  • Active licensed Registered Nurse; will consider LISW with extensive health plan experience.
  • At least 8 years of broad medical management and health plan quality leadership experience, including NCQA accreditation, in a health insurance organization.
  • Ability to drive program development and meet deadlines.
  • Ability to communicate and influence a variety of constituents.
  • Ability to identify and implement program changes as needed.
  • Energized by and comfortable with rapidly evolving organizational needs and environment.

Finishing Touches (Preferred):

  • Experience in the New Mexico health insurance market.
  • National certification in healthcare quality.
  • Bilingual speaking, writing, and reading skills.

 

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

 

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