• Interfaces collaboratively with Appeals, Grievance and Case Management departments in the review of quality requirements for regulatory reporting needs• Evaluates, interprets, and summarizes accreditation guidelines and manages the process for accreditation activities. • Conducts the ongoing evaluation and interpretation of quality standards and accreditation standards to ensure compliance through client decision communications • Serves as expert resource to quality committees and business owners across the organization. • Leads and provides oversight of quality studies/projects. • Facilitates project management and develops comprehensive accreditation work plans by establishing deliverables, accountabilities, and timelines. • Performs quantitative and qualitative analysis of quality related data and reports activities, improvements, and recommendations to internal and external clients

• Evaluates, interprets, and summarizes accreditation guidelines and manages the process for accreditation activities. • Identifies appropriate resources and accountabilities for project teams involved with accreditation. • Conducts the ongoing evaluation and interpretation of quality standards and accreditation standards to ensure compliance through documentation, including reporting and measurement studies/ methodologies. • Reviews Medical records for timeliness, gaps in care and appropriate medical pathways • Leads and provides oversight of quality studies/projects. • Facilitates project management and develops comprehensive accreditation work plans by establishing deliverables, accountabilities, and timelines

• Interfaces collaboratively with internal and external clients in the review of quality requirements and implementation of appropriate interventions to meet compliance. • Interfaces collaboratively with Appeals, Grievance and Case Management departments in the review of quality requirements and implementation of appropriate interventions to meet compliance• Monitor regulatory agencies for changes in laws, requirements etc. relevant to the government program and communicate changes to affected business unit(s) and monitor to verify conformity within required timeframe. • Manages the overall accreditation processes and resources required to successfully lead the team. • Evaluates, interprets and summarizes accreditation guidelines and manages the process for accreditation activities. • Identifies appropriate resources and accountabilities for project teams involved with accreditation. • Conducts the ongoing evaluation and interpretation of quality standards and accreditation standards to ensure compliance through documentation, including reporting and measurement studies/ methodologies. •Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures

Provides leadership, administrative and management support, strategic planning and overall direction of the regional Quality Improvement and Quality Management programCreation of provider programming to enhance VBPs, MIPs and Quality payment programs•Has accountability for the overall regional success and in meeting and exceeding all QI program goals and metrics including HEDIS, CAHPS, and AccreditationConducts EMR audits for documentation improvement and member continuation and coordination of care.•Aligns and coordinates the work within the QMP Centers of Excellence for: HEDIS data collection, Data Analytics and Reporting, Accreditation, Member Surveys, Regulatory Adherence, and Member Activation and Engagement. Utilizing the expertise, standard process, and capabilities of these areas to enhance quality program performance of the plan•Works closely with Health Plan leadership to align goals, strategies, tactics, drives deployment and provide updates, feedback, metrics as well as identification for opportunities for improvement for Star Ratings and other goal driven improvement metrics•Develops annual goals and objectives for the region in alignment with overall Quality Management & Performance shared service and corporate goals & strategies to meet and exceed established program objectives•Aligns program financial & budget reports and information and maintain neutral budget•Conducts or directs assessments and produces analysis documents to guide strategic planning•Forms internal and external strategic relationships which will support program innovation, growth, expansion and the development of new programs•Interaction with regulatory agencies •Provides leadership to and is accountable for the performance and direction through multiple layers of management and senior level professional staff

*Overseeing the coordination of HEDIS reports, analyses, outreach, training, and data collection*Working with clinical and administrative staff to design and implement HEDIS initiatives*Providing support for quality improvement initiatives, health management programs, and behavioral and preventive health activities*Participating in the review of medical records to abstract clinical information for HEDIS reporting