Own regulatory and accreditation deliverables (NCQA, PIPs, state requirements), ensuring on-time submission and sustained audit readiness
Drive audit readiness by establishing and maintaining scalable documentation, workflows, and submission processes that support compliance and reduce risk
Leverage performance data to identify gaps, lead root cause analysis, and drive targeted quality improvement initiatives that enhance outcomes
Oversees the creation and implementation of programs relevant to the organization's strategic initiatives involving Health Services, clinical and operational quality administration
Designs and facilitates the development of various programs/systems, work flows, and integration efforts in alignment with Corporate, market, contractual, regulatory and quality requirements
Acts as the content and technical subject matter expert to the operation managers and directors for key project initiatives including the development of detailed work plans, facilitating route cause analysis, identifying and socializing process enhancements, setting deadlines, assigning responsibilities, and monitoring/summarizing project progress

A Bachelor's Degree in a related field, or equivalent work experience in Business, HC Management, or Nursing
5+ years of experience in direct program development, program management, and/or project management, preferably in a healthcare environment
3+ years of experience in managed care, plus utilization management, care coordination, disease management, Medicare, Medicaid, DSNP, dual eligibles, PCMH
2+ years of experience in design, develop and implement STARS, CAHPS, HEDIS and other enterprise quality related programs across a variety of settings including: Defining the eligible population, service mix, delivery system configuration and financing
Integration of behavioral, clinical, social, and community health care for members with multiple chronic conditions
Working with multiple market leaders to coordinate consistent quality initiatives
Conducting assessments, contractual reviews, and business plans for new quality improvement, including internally sourced or vendor sourced quality programs, and/or the integration of innovative approaches to defined programs to improve quality ratings company wide

Quality Program Development Manager

Key skills