Sr. Director Quality & Health Plan Governance

Company: Kaiser Permanente
Location: Portland
Posted on: April 4, 2025

Job Description:

Job Summary: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 include quality oversight of network contracted facilities such as hospitals, skilled nursing facilities, DME, and utilization management. Familiarity or experience with HRO is preferred.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.Essential Responsibilities:

• 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 develop long-term strategies; serving as the primary contact during significant outbreak containment protocols and efforts; and consulting with Administration on infection control implications of architectural design, renovation, and construction.
• Directs risk management efforts by defining and presenting the standards for corrective action plans for improvement identified through utilization review, clinical records audit, claim denials, patient satisfaction surveys, and auditing surveys across the organization; utilizing information gathered from root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches to establish new policies and procedures to mitigate future risk; defining the standards for health outcome analysis to continuously monitor oversight effectiveness.
• Oversees and is accountable for patient safety programs and initiatives by serving as the primary contact during significant event management and response to safety hazards, accidents, incidents, threats, and significant events; and collaborating with executive management and external personnel to develop patient care and satisfaction programs which aim to improve patient flow, clinical support, patient services, and seamless transition of care.
• Oversees development of new clinical quality improvement programs by maintaining relationships with key stakeholders, senior management, and external stakeholders to influence the long-term strategic plans for guidelines, metrics, and operational definitions of quality improvement, and ensuring the sustainability of the program; serving as a subject matter expert on a variety of health concepts, regulatory requirements, and change management principles to ensure KP strategies prioritize programs that optimize clinical quality, safety, or health outcomes; and providing insight into KPs capability of realizing strategic opportunities to develop as a learning organization by advocating for the program and consulting with executive management, technology stakeholders, and external vendors.
• Oversees the systems, procedures, and forms to improve data management programs and utilizes data to monitor and improve performance of all worker and patient safety programs by ensuring the quality improvement monitoring agenda for the organization includes all aspects of data management and analysis of trends and patterns of practice are integrated into long-term strategic plans; acting as a subject matter expert in interpreting and applying data from databases, vital statistics, hospital patient discharge data, claims, and other relevant health sources to guide long-term KP strategy with data driven advice; and presenting and advising on the application of reports (e.g., infection control research, utilization reviews, population health needs analysis, patient satisfaction) in specified formats for executive internal and external stakeholders in order to guide long-term planning.
• Oversees regulatory audits and survey efforts by serving as the primary contact between applicable government, regulatory, other organization, and management for onsite visits and evaluations; establishing the long-term standards for requested audit documentation, information, reports, and tools throughout the auditing process; establishing the long-term standards for audit documentation, information, and reports; and forecasting and establishing continuous survey readiness activities to adapt to changes in regulatory and KP requirements.
• Defines the future direction and standards for the evaluation of the cost effectiveness, practicality, and appropriateness of medical care given to patients by ensuring case reviews are completed and followed up on; partnering with key stakeholders to empower practitioners and department to follow standard operating procedures for treatment for specific medical codes to ensure equal and timely access to care; advocating with key stakeholders to resolve systematic concerns to ensure current patient treatment plans meet patient needs in a timely manner; defining the standards for population health needs to drive the direction of policy to meet current and future population health needs, such as community health concerns, access to transportation, knowledge of rights, reducing no shows, and others; and utilizing results from previous patient case reviews to advocate for policy and technology changes to improve utilization.Minimum Qualifications:
  • Minimum four (4) years of experience managing operational or project budgets.
  • Minimum nine (9) years of experience in a leadership role with or without direct reports.
  • Minimum six (6) years of experience with databases and spreadsheets.
  • Minimum four (4) years of experience delivering training programs.
  • Minimum eight (8) years of experience in clinical setting, health care administration, or a directly related field.
  • Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum nine (9) years of health care experience or a directly related field OR Minimum twelve (12) years of experience in health care or a directly related field.
    • Professional Healthcare Quality Certificate within 24 months of hire OR Professional in Healthcare Risk Management Certificate within 24 months of hire.Additional Requirements:
      • Knowledge, Skills, and Abilities (KSAs): Negotiation; Business Process Improvement; Risk Management; Compliance Management; Health Care Compliance; Health Care Policy; Health Care Data Analytics; Learning Measurement; Community Health; Health Care Coding; Consulting; Managing Diverse Relationships; Delegation; Development Planning; Project Management; Risk Assessment; Health Care Quality Standards; Quality Improvement; Quality Assurance and Effectiveness; Evidence-Based Medicine Principles; Infection Control.
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Keywords: Kaiser Permanente, Portland , Sr. Director Quality & Health Plan Governance, Healthcare , Portland, Oregon