The regulatory function is vital in making safe and effective healthcare products available worldwide. Individuals who ensure regulatory compliance and prepare submissions, as well as those whose main job function is clinical affairs or quality assurance are all considered regulatory professionals.
One of our most valuable contributions to the profession is the Regulatory Code of Ethics. The Code of Ethics provides regulatory professionals with core values that hold them to the highest standards of professional conduct.
Like all professions, regulatory is based on a shared set of competencies. The Regulatory Competency Framework describes the essential elements of what is required of regulatory professionals at four major career and professional levels.
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The Director of Quality Improvement is responsible for daily operations associated with the Quality Improvement Department and is accountable for establishing and implementing an effective quality improvement program essential to meet state, federal and accreditation requirements. The Director is responsible for providing leadership to achieve the above goals as well as best practice performance levels in quality improvement. This role requires that the individual interfaces with a diverse range of clinical and administrative professionals, resolves complex policy and service issues and directs oversight of reporting activities required by regulatory agencies. This position is responsible for identifying and recommending initiatives as a result of evaluation of the health plan's activities and member population need. They include development and monitoring of quality indicators for plan performance, support of the Quality Improvement Committee, and promotion of continuous quality improvement activities within the entire organization.
Responsible for all aspects of the Quality Improvement program for CHRISTUS Health Plan, including such activities as
Budgetary responsibility for areas of related to the Quality Improvement Department
Identifies need for and leads staff in development and revision of policies and procedures governing Quality Improvement Operations
Provides supervision and support to the RN Manager and assures oversight of provider audits, education, associate training and review, work plan development, corrective action oversight, member safety and potential quality of care issue identification and investigation
Oversees physician education efforts regarding HEDIS and any other needed education for success. Assures that all education is provided on an ongoing basis and includes the most up to date requirements and/or guidelines, as well as coordination with the Network Management field representatives
Responsible for NCQA and URAC or other regulatory agency readiness, accreditation and coordination with accreditation agency. Leads efforts to prepare for audits, which includes departmental education, training/meetings and quality communication
Quality Improvement Committee (QIC) participation, which may include being the committee Chair. Assurance that all required business areas are reporting in accordance to the QIC Work Plan.
Oversight of HEDIS Improvement initiatives in conjunction with quality HEDIS subject matter expert, data analyst and IT support. Oversight of the HEDIS vendor, audit process, reporting of results to QIC and Board of Directors, comparing results to bench-marking data available, development of improvement activities and implementation of actions to improve.
Assures that the annual Clinical Quality Management Program (CQMP) evaluation is complete timely as well as the Quality Program Description and Work Plan
Oversight of the Peer Review Process (PRC), communication with external providers as well as Medical Director including coordination of meeting time, oversight of RN PQI investigation and staffing with MD, provider communication and upkeep of log and letter templates. Quarterly reporting to QIC for all PQI's for all LOB's
Maintains Quality Improvement Activities (QIA's) and Performance Improvement Plan's (PIP's)
Ensures that department priorities are aligned with Senior Leadership by meeting regularly with Business Unit leaders through the free and open exchange of information.
Oversees quality contribution to member and physician education to include research and development and review of written material.
Participates in appointed committees and sub-committee's as well as update inter-departmental structures as well as committee structure as needed
Follow the CHRISTUS guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
Bachelor Degree. Master's degree in Health Care Management preferred
Excellent knowledge of accrediting standards relating to managed care operations/health plans
Solid background in facilitation skills, process analysis tools and quality theories
Strong interpersonal skills, including the ability to interact effectively with staff, employees, supervisors, managers, physicians, and hospital executives
Effective verbal and written communications, and organizational skills
Knowledge of computer systems and QI applications
Ability to work collaboratively and effectively in intense environment
Excellent speaking ability, judgment, initiative and problem solving abilities
Considerable discretionary decision making
Ability to handle and resolve complex issues
Ability to work a flexible work schedule
Meeting deadlines in high pressure environment
High degree of personal accountability and integrity demonstrated
Occasional Regional travel as necessary to achieve job responsibilities and strategic objectives.
Long term project management skills
Analytic ability to prepare status reports and document procedures
Minimum five years quality management experience in the Health Care field
Minimum five years of experience in Quality Improvement within a health plan
Minimum five years of experience in leading effective HEDIS programs and accreditation
Minimum five years of managed care experience
Minimum of 4+ years of management experience
Knowledge and experience regarding HEDIS, NCQA, URAC, QIC facilitation, Peer Review Committee oversight and regulatory
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.