Job DescriptionYour Role The Clinical Quality [Commercial Populations] team is accountable for the organization's quality ratings, preventive and primary care outcomes for Blue Shield of California's Commercial members, and financial risks associated with quality performance. The Director, Clinical Quality will report to the Senior Director, Clinical Quality. In this role you will be accountable for provider network quality performance within the capitated (HMO), fee-for-service (PPO), self-funded and specialty care networks. This includes accountability for designing and executing strategic roadmaps to achieve quality and financial targets, as well as managing a cross-functional, statewide team.
This person is required to live within 50 miles of the Oakland, Rancho Cordova, Woodland Hills or Long Beach office locations. ResponsibilitiesYour Work In this role, you will:
- Design, implement, and sustain enterprise quality programs aligned with the Quality Roadmap and Work Plan with specific accountability to drive quality outcomes performance with large medical systems, small physician practices and specialty care teams
- Accountable for quality improvement and assurance across current and anticipated member populations, using data to design multi-year HEDIS and CAHPS improvement pathways and change management initiatives within complex systems
- Build and maintain strategic partnerships across clinical, operational, technical, and legal teams in order to translate enterprise business strategy into actionable plans that support care teams across the state of California in medical, dental and vision care
- Lead collaboration on integrated quality initiatives spanning care delivery, pharmacy, wellness, and technology at all levels, including directly with Chief Medical Officers, Chief Nursing Officers and Medical Directors by demonstrating HEDIS expertise and a variety of influence techniques
- Serve in a leadership role with provider partners, ACOs, and enterprise quality governance bodies in order to lead and direct decisions about return-on-investment and provider investment tradeoffs
- Own annual quality program planning, evaluation, and budget development with specific accountability for creating successful strategic plans for provider incentives, clinical innovation funding, and penalty risk management with three-year time horizons
- Lead teams using data-driven insights, industry best practices, and continuous improvement methodologies including hiring, firing, onboarding, promotion and reward, as well as creating workforce and staffing plans
- Adapt quality strategies and program design in response to evolving business and regulatory needs, including close partnership with Senior leadership to align Quality outcomes, technology and artificial intelligence strategies
QualificationsYour Knowledge and Experience - Requires Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
- Requires at least 10 years prior relevant experience achieving outcomes in HEDIS, CAHPS or other publicly reported quality ratings targets
- Requires 6 years of prior people management experience with direct responsibility for supervising, coaching, and evaluating direct reports
- This person is required to live within 50 miles of the Oakland, Rancho Cordova, Woodland Hills or Long Beach office locations.
- Master's degree or equivalent in healthcare administration, public health, or a related field and Lean Six Sigma, or a comparable planning, strategy, program, or improvement certification preferred
- Requires experience within a California health plan or comparable regulated payer environment and applying structured change-management methodologies within the California healthcare system
- Requires demonstrated experience leading annual or multi-year planning in a complex, matrixed organization
- Requires at least 6 years' experience implementing quality interventions for and with preventive care and behavioral health or dental providers
- Experience with health equity interventions within clinics, practices or medical groups preferred
- Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment as well as required travel within the state of California. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of the workday
HybridThis role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
About Blue Shield of CaliforniaAs of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
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