Quality & Accreditation Director

Description

POSITION OVERVIEW

Harbor Health is seeking a seasoned, detail-oriented Quality & Accreditation Director to lead the implementation, refinement, and oversight of a comprehensive enterprise-wide Quality Management Program supporting our Texas fully insured Individual & Family Plan (IFP/Marketplace) and large group (25+ employees) commercial products. Harbor Health holds NCQA Health Plan Accreditation at Interim status, and this leader will guide the organization through the full (First) survey and sustain accreditation through renewal.

This role will serve as our internal NCQA expert, coordinating cross-functional efforts to put NCQA-reviewed policies into practice, build the implementation evidence and performance results required for a full survey, and maintain continuous survey readiness for our health plan and applicable NCQA programs for our medical group while driving performance improvement initiatives and maintaining regulatory compliance with Texas Department of Insurance (TDI), CMS Marketplace/QHP, and other applicable requirements. Reporting to the Senior Director of Compliance, this position is critical to establishing Harbor Health's foundation for quality excellence as we scale our payvider model - and is central to our mission of transforming healthcare through an integrated approach to care delivery and coverage.

POSITION DUTIES & RESPONSIBILITIES

NCQA Accreditation, Continuation & Readiness

• Lead all aspects of NCQA accreditation continuation, including progression from Interim status through the First survey and subsequent renewal surveys, for IFP/Marketplace and large group commercial product lines.
• Own the integrated roadmap and timeline from Interim status to the First survey, including survey application and submission dates, look-back requirements, and owner accountability by standard and element.
• Implement and refine the policies and procedures reviewed at the Interim stage, translating them into operational workflows, and revising them based on implementation gaps, NCQA feedback, and standards changes.
• Ensure documentation of implementation is produced and retained as work occurs, including committee minutes, program documentation, reports, and file review samples, so that evidence is complete within NCQA look-back periods.
• Ensure NCQA status and timelines satisfy QHP accreditation requirements for continued Marketplace participation.
• Interpret and apply NCQA standards across the organization, developing and maintaining comprehensive compliance documentation and tracking tools (including file review preparation, evidence repositories, and mock surveys).
• Oversee all submission processes and ensure organizational readiness for reviews (including survey tool submission, file reviews, and responses to NCQA preliminary reports and follow-up requests).
• Conduct gap analyses, establish detailed project plans, and serve as the primary liaison for NCQA and regulatory audits (NCQA, TDI, and CMS).
• Maintain accreditation timelines and monitor overall accreditation status across the enterprise.
• Monitor NCQA standards updates and annual program changes, and translate them into policy, process, and workflow changes.
• Evaluate and plan for NCQA recognition or accreditation programs relevant to our medical group and care model (e.g., Patient-Centered Medical Home, credentialing, health equity, population health).

Quality Program Leadership

• Manage, implement, and continuously refine Harbor Health's enterprise-wide Quality Management Program (QMP), ensuring alignment with Texas and federal regulations (including TDI quality improvement requirements and the ACA Quality Improvement Strategy (QIS) for Marketplace plans) and NCQA standards.
• Manage the Policy and Procedure Library, including version control, annual review cycles, and revisions driven by implementation experience and NCQA feedback, facilitating Quality Committees (e.g., QI Committee, with required governing body reporting) and ensuring proper documentation of all activities.
• Lead annual evaluations (QM Program Description, Work Plan, and Annual Evaluation) and performance reporting to demonstrate continuous quality improvement across the organization.
• Partner with Utilization Management, Credentialing, Network, Pharmacy, Member Services, and Population Health leaders to ensure the QMP integrates with their NCQA-required processes.

Data & Performance Monitoring

• Partner with analytics teams to track, interpret, and report on quality metrics and performance indicators.
• Build and maintain a scorecard that tracks policy implementation, committee activity, program results, and survey readiness by standard from Interim status through the First survey and renewal cycles, with regular reporting to leadership and the governing body.
• Lead the measurement and analysis of quality programs and activities required for a full survey, including baseline results, barrier analysis, interventions, and re-measurement.
• Support the establishment and monitoring of benchmarks in HEDIS, CAHPS (including the QHP Enrollee Experience Survey), member complaints and appeals, access to care and availability, and care coordination.
• Oversee HEDIS reporting, including the annual HEDIS compliance audit, and Marketplace Quality Rating System (QRS) submissions; establish baselines and track improvement ahead of scoring on HEDIS and CAHPS measures.
• Use NCQA Quality Compass and other benchmarks to set targets and track IFP and large group performance by product line.
• Drive measurable improvements in member outcomes and organizational performance through data-informed decision-making, including identifying and addressing disparities in care.

Cross-Functional Coordination

• Collaborate with departments across Harbor Health to implement aligned quality initiatives that support our integrated payvider model, and hold standard owners accountable for implementation, documentation, and ongoing compliance.
• Ensure delegated entities and partner organizations meet NCQA performance expectations and maintain quality standards consistent with Harbor Health's mission, including pre-delegation assessments, delegation agreements, and annual oversight.
• Work with clinical leadership of the medical group to align provider-level quality performance, care gaps, and documentation with plan-level HEDIS and accreditation requirements.

Staff Supervision & Training

• Supervise NCQA project staff and quality personnel, providing mentorship and oversight for talent development in quality-related roles.
• Develop and deliver comprehensive NCQA training across all departments, with emphasis on operationalizing policies and sustaining survey-ready documentation.
• Provide onboarding and ongoing education on NCQA and regulatory quality standards throughout the enterprise.

DESIRED PROFESSIONAL SKILLS & EXPERIENCE

Required

• Bachelor's degree in Nursing, Healthcare Administration, Public Health, or a related field
• 8 years of experience in healthcare quality improvement and/or compliance within a health plan, delegated entity, or integrated delivery system
• Demonstrated experience leading and sustaining NCQA accreditation efforts for a licensed health plan or delegated entity, including direct involvement in at least one successful NCQA survey
• Strong understanding of NCQA Health Plan Accreditation standards, HEDIS, and CAHPS
• Demonstrated experience implementing and refining quality policies and procedures and documenting evidence of implementation for NCQA file review and look-back requirements
• Working knowledge of Texas commercial health plan regulation (TDI) and ACA Marketplace/QHP quality requirements
• Experience with commercial and/or Marketplace products; fully insured individual and group experience strongly valued
• Proven success in leading cross-functional quality initiatives and managing complex projects
• Excellent communication, organizational, and analytical skills
• Mission-driven with passion for improving health outcomes in underserved communities
• Collaborative approach with ability to work effectively across teams, disciplines, and partners
• Results-oriented focus on measurable impact, compliance, and sustainable processes
• Adaptable and able to thrive in a dynamic, fast-paced healthcare environment

Preferred

• Master's degree in Healthcare Administration, Public Health, or a related field
• Certified Professional in Healthcare Quality (CPHQ) or NCQA-related certification (e.g., NCQA Certified HEDIS Compliance Auditor, PCMH CCE)
• Experience working in an integrated delivery system, payvider, or startup environment
• Experience guiding a health plan from NCQA Interim status through a First survey, or leading renewal surveys
• Experience with delegation oversight and Marketplace QRS/QHP reporting
• Bilingual in English/Spanish

WHAT WE OFFER

• Competitive salary and incentives
• Generous PTO
• 10 paid holidays
• Medical, Dental, and Vision Insurance
• 401(k) Investment Plan
• Company Equity
• Professional development and growth opportunities