Sr. Director Quality & Health Plan Governance

Oversight of Medicare and Medicare 5 Star, Medicaid Quality programs, Performance Guarantees, HEDIS, Accreditation, Regulatory & Licensing. Have responsibility to work directly with National Quality and oversee HP Quality Oversight Committees. Other responsibilities, quality oversight of network contracted facilities such as hospitals, skilled nursing facilities, DME, utilization management. Familiarity or experience with HRO.

Oversees the development of quality strategies in alignment with KFHP strategic priorities, mission, and vision. Oversees organizational coordination, identifies trends and issues, and directs leaders to create action plans based on reviews of regional quality reports. Engages in external and internal thought leadership to anticipate emerging issues and trends and to identify strategic opportunities for improvement and establishes organizational priorities. Strategically identifies clinical quality improvement possibilities and establishes metrics and goals that will motivate others to develop high impact action plans. Sets a leadership tone for ensuring quality issues are identified and resolved. Serves as a strategic thought leader for clinical quality processes and regulations and empowers others to develop processes and tools to help increase collective knowledge across the organization. Develops capabilities of teams to analyze and monitor key results from data analysis and review and approve quality policies. Leads teams in the oversight of and coordination with the functions of Quality Committees and subcommittees. Establishes standards and processes for the annual approval of Quality Program description, work plans, and annual evaluations.

• Builds organizational capacity and prepares high potentials for growth opportunities and advancement; builds collaborative networks inside and outside the organization for self and others.


• Provides framework for soliciting and acting on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement.


• Models and drives continuous learning and oversees the recruitment, selection, and development of talent; stays current with industry trends, benchmarks, and best practices; ensures performance management guidelines and expectations to achieve business needs.


• Acts as a thought leader on industry trends, benchmarks, and best practices; shares best practices within and across teams to drive improvement.


• Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning cross-functional resource plans with business objectives.


• Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact across teams.


• Oversees the operation of multiple units and/or departments by identifying member and operational needs; ensures the management of work assignment allocation and completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies.


• Engages strategic, cross-functional business units to champion and drive support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress and ensures resolution of escalated issues.


• Sets and communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; obtains and distributes resources.


• Anticipates and removes obstacles that impact performance; addresses performance gaps and implements contingency plans accordingly; ensures teams accomplish business objectives; serves as a subject-matter expert and trusted source to executive leadership; provides influence and consultation in the development of the larger organizational or business strategy.


• Serves as the subject matter expert for clinical quality improvement processes and regulations for executive internal and external stakeholders, executive sponsors, business owners, and external quality improvement organizations by: providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation, and advising on the long term strategies of KP to address the current climate and potential changes which may have long term effects on business operations; proactively engaging internal and external committees, projects, and relevant initiatives to actualize change and determine necessary infrastructure changes to move QA initiatives forward and ensure future KP compliance, as well as to communicate to senior leadership on the various changes and rationale for change; fostering and driving collaborative, results-oriented partnerships with practitioners, staff, management, and/or departments across clinical and administrative roles to ensure current and future compliance, and influencing the development and direction of KP policy and strategy to be compliant and adaptive; forecasting and determining the direction of future educational programs to raise awareness for current and changing regulation requirements, internal concerns, and system/database usage; and identifying and removing barriers to process improvement issues, weighing practical, technical, and KP capability considerations in addressing issues, and advising on policy changes.


• Ensures the outcomes of the quality of care complaints and review process by: representing KP in grievance meetings, cases, reviews, referrals, and other mechanisms; responding to and directing the preparations of all documentation, records, and information requested for specific and highly sensitive patient case reviews; reporting trends in the process flow of investigations and claims for red flags, appeal reasons, and overturns, reporting results, and advising on strategic direction to reduce reoccurrences; and defining the standards for the surveillance of quality improvement metrics, cases, quality care incidents, and near misses according to established protocols to ensure equal/consistent application of KP policies.


• Oversees infection prevention and control programs to improve employee and patient safety by: presenting information from epidemiological investigations, simulations, and research of significant clusters of infection or serious communicable disease concerns as a part of prevention, surveillance, and outbreak management to internal and external executive stakeholders in order to guide and devel