TO Quality Management Director

Job Title: Quality Management Director

Job Code: QM DIR

Department: Infrastructure Development

Division: Tribal Option

Salary Level: Exempt 6

Reports To: Director of Quality/Patient Safety

Last Revised: March 2025

Primary Function

The Quality Management (QM) Director will report to the Director of Quality Management and Patient Safety of the Cherokee Indian Hospital Authority (CIHA) and the Tribal Option Director. The QM Director, under the leadership of the Director of QM and Patient Safety, and following a matrix team model, will be responsible for the overall management of the Tribal Option Quality Management plan, including developing the necessary infrastructure and reporting processes to meet the requirements set forth in accordance with the NC Division of Medical Assistance and ensure adherence to national accreditation guidelines.

Job Description

The position is responsible for establishing, implementing, monitoring, and the annual evaluation of the Tribal Option Quality Management program. The position must work collaboratively across all departments to ensure awareness of the goals and expected outcomes detailed in the QM plan and develop a process to continuously identify areas for study and improvement. The QM Director, in coordination with the Medical Director, is responsible to develop a Quality Assessment and Improvement program and identify Performance Improvement Plans (PIPS) that focusing on improving the healthcare of members served under Tribal Option, addressing issues that could impact member safety and/or improving organization performance for areas that are outliers of contractual requirements, including establishing CIHA policy and procedures and adherence to national accreditation standards.

Essential Duties and Responsibilities

Administration

• In collaboration with the Medical Director and Leadership team, ensures that the guiding vision, mission and values are incorporated into the development and operations of the Tribal Option's quality management program and division.
• Under the direction of leadership members, develops statistical, data and quality management reports to analyze and evaluate Tribal Option performance against contractual defined performance standards.
• Develop and implement systems for gathering, managing and reporting QM data.
• Serve as a liaison with regulatory and accrediting bodies to ensure compliance with standards.
• Assists in the organization and preparation for all Tribal Option reviews, including; state Implementation Management Team readiness reviews and quarterly updates, annual External Quality Review, and initial and ongoing national accreditation reviews.
• Demonstrate knowledge of managed care and healthcare principles: legal, regulatory and confidentiality.
• Ensures CIHA Medical Director is informed of identified quality, health and safety concerns, and trends related to complaints and grievances.
• Supports all efforts to achieve readiness to obtain and maintain national accreditation for health plan management functions, develops, and maintains infrastructure and systems to monitor ongoing compliance with standards.
• Monitors compliance with terms and conditions of DHHS Tribal Option PCCMContract.
• Examines processes and implements policies and procedures to continually improve upon the operation of the Tribal Option.
• Prepare reports as required and requested.
• Organizes and facilitates Quality Management Committee.
• Ensures appropriate monitoring and oversight of all functions delegated to outside entities.
• Review data with proper business units to determine operational impacts and needed actions; elevate issues, trends, areas for improvement and opportunities to management.

Fiscal and Business Management

• Assists with the development of analytic reports to help manage clinical/financial risk, including over and under-utilization.
• In coordination with clinical management and finance management, establish a program that evaluates provider and clinical outcomes to ensure quality elements are present in and meet requirements as part of an alternative payment model that may be implemented under the Tribal Option.

Quality Management

• Under the guidance of the Medical Director, ensures, develops and implements a quality management plan that helps ensure patient health and safety.
• Conducts annual evaluation of the Tribal Option Quality Management plan and recommends updates and corrective actions as needed.
• Understands available data sources and uses them to extract and evaluate available data and implement processes to effect improvement.
• Maintain and utilize systems for gathering, managing and reporting QM data.
• Initiate and develop educational resources to support the needs of the Quality Management Plan.
• With guidance from the Medical Director, ensure the development and implementation of quality management operational policies and procedures.
• Maintain an internal review process to ensure accuracy of utilization management decisions, timeliness of decision-making and appropriate notification.
• Maintain care coordination documentation review process ensuring accurate and timely documentation of care coordination documentation.
• Ensures accuracy and timely submission of all NC Division of Medical Assistance requirements outlined in Section K of the Tribal Option contract.
• Develops policies and procedures related to all aspects of managing member grievances and monitors timely response and reports trends and outcomes.
• Work cooperatively with the Utilization Management staff, Patient Access, Administration, network providers to effectively resolve patient complaints.
• Establishes mechanisms to identify, review and report sentinel (incidents) events for all members covered under the Tribal Option.
• Ensure sentinel events/incidents are reported to the state in accordance with state and federal law.

Education/Experience/Minimum Qualifications

• A BA/BS in human services related field and quality management experience required.
• Minimum five (5) years of recent quality management experience required.
• Two (2) years of managed care experience, preferred.
• Knowledge of Medicaid managed care and previous work with tribal health care preferred.

Other requirements:

• Excellent verbal, written and interpersonal skills a must.
• Excellent analytical and organizational skills with strong attention to details.
• Proven ability to solve problems and make sound decisions.
• Ability to work collaboratively with cross-functional agency units and departments.
• Ability to work independently and within a team environment.
• Ability to function effectively within an ever-changing environment to meet deadlines and reprioritize as necessary.
• Proficiency in MS Office and Managed Care tools and platforms.

Supervision Received

The QM Director reports to the Director of Quality Management and Patient Safety and Tribal Option Director. The employee exercises a moderate degree of independence; may consult with the Tribal Option Director, Medical Director and other Directors in resolving issues and maintaining consistency and continuity across agency operations.

Contact with Others

The personal contacts are with DHHS Officials, EQRO, and national accreditation reviewers, subordinates, co-workers, and higher-ranking managers, leadership of outside entities, patients, and members of the community. The purpose of the contact is to exchange information, coordinates external audits and reviews, improve care, and resolve differences between subordinates.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA's guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.