VP Quality Health Plan

Presbyterian Healthcare Services

Albuquerque (NM)

Hybrid

USD 180,000 - 280,000

Full time

14 days+

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Benefits offered by this job

Medical coverage (full)

Retirement plan with employer match

Paid time off

Wellness programs

Education opportunities

Life insurance

Disability programs

FSAs

Job summary

Presbyterian Healthcare Services in Albuquerque seeks a strategic Vice President of Quality to lead quality improvement and accreditation activities across plans, ensuring NCQA accreditation, Star ratings, and compliance with Medicaid and regulatory requirements.

The role directs CQI programs, designs continuous quality infrastructure, and partners with executives to advance patient care quality while managing a multidimensional team and budget.

Qualifications

Bachelor's degree in Health Care Administration, Public Health, Nursing, or related field required.
10+ years progressive leadership in Quality Improvement programs.
Active clinical licensure required; RN licensure preferred.
CPHQ certification preferred.
Experience with Medicaid regulations and NCQA accreditation required.
Experience in managed care organization preferred.

Responsibilities

Lead development and management of quality improvement and accreditation activities.
Oversee NCQA reaccreditation and regulatory compliance.
Direct Star ratings and Medicare/Medicaid initiative programs.
Lead CQI processes and collaborate with PHP/PHS entities.
Manage staff and budget for quality programs.
Coordinate with providers and accreditation bodies.

Skills

Leadership

Quality improvement

Budget management

Regulatory compliance

Education

Bachelor's degree in Health Care Administration/Public Health/Nursing

Master's degree in related field

Active clinical licensure

RN licensure preferred

CPHQ certification preferred

Tools

NCQA accreditation

Medicaid regulations

Job description

Location Address

9521 San Mateo NEAlbuquerque, NM 87113-2237

Summary

The Vice President of Quality provides leadership for all activities relating to the development and management of the Plan's quality improvement and accreditation activities including NCQA, contractual and regulatory quality requirements and measures for all lines of business including but not limited to HEDIS/Performance Improvement, clinical quality programs, clinical vendor management (excluding Pharmacy Benefit Manager). This role also develops and oversees strategies, policies and processes to ensure implementation of programmatic initiatives related to these areas with both internal and external stakeholders.

Work Arrangement

Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, WA, and WY.
Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday.

Job Description

Responsible for executing on operational strategies and programs using complex analytics and reporting to support Medicare Star Ratings, HEDIS, and Quality Intervention Programs. Responsible for the annual HEDIS submission, PHP Medicare Star Program Ratings, NCQA accreditation, and regulatory and contractual compliance.
Directs the activities for Performance Improvement intervention programs, HEDIS/Star analytics and reporting and abstraction activities. This key position works in collaboration with a variety of PHP/PHS entities, departments, administration, and leadership bodies to ensure organizational improvement efforts align with accrediting, licensing, and legal requirements.
Designs, implements and leads the Plan's continuous quality improvement infrastructure.
Acts as an internal consultant and resource to all levels of the organization relative to CQI processes and standards.
Works in collaboration with the broader PHS system to identify opportunities, implement innovations and evaluate outcomes.
Oversees the development and execution of Stars strategy in conjunction with key business partners.
Responsible for the development and execution of the organizations Medicare and Medicaid Sustainability and strategy in determining an approach to securing and maintaining an annual Medicare Advantage Star Rating of 4.0 or higher, meeting 100% of Medicaid Performance Measure targets, and ensuring the maintenance of NCQA health plan accreditation for all lines of business.
Leads all Plan activities for National Committee for Quality Assurance (NCQA) re‑accreditation.
Responsible for the ongoing administrative, clinical, fiscal and programmatic interaction with NCQA. Communicates with NCQA as needed to ensure the Plan is informed of all events and circumstances that affect the initial and on‑going achievement of NCQA accreditation.
Is responsible for overall Utilization Program Compliance as it pertains to accreditation obligations.
Oversees quality of care studies (based on targeted areas for quality management and quality improvement). This includes the following: analyzes data, performs root cause analysis, facilitates plans for improvement, provides technical support to Plan managers, and conducts re‑measurement activities to assess performance improvement.
Monitors quality performance indicators; prepares reports for quality oversight committees; develops vehicles to communicate performance to providers; and identifies clinical and administrative concerns for further investigation and analysis.
Develops and manages communications with providers, government and accreditation organizations with respect to results of quality management studies, including oversight of remedial action as required.
Directs the supervision of subordinate staff to include hiring, work allocation, scheduling, training and professional development, problem resolution, performance evaluation and related supervisory activities. Maintains budgetary responsibility for responsible departments.
Directly manages 5‑15 staff and indirectly oversees up to 40 staff.

Education

Bachelor's degree in Health Care Administration, Public Health, Nursing, or related field or the equivalent combination of training and experience is required.
Master's degree in related field strongly preferred.
Active clinical licensure required.
Active clinical licensure as a Registered Nurse strongly preferred.
Pre‑employment background check.
CPHQ certification strongly preferred.

Experience

10+ years progressively responsible experience in leading Quality Improvement Programs, which includes supervision of staff and budget management, is required.
Comprehensive knowledge of Medicaid regulations, guidelines and standards is required.
Comprehensive knowledge of accreditation organizations such as NCQA is required.
Experience within a managed care organization is strongly preferred.
Previous experience in designing and leading an accreditation process is strongly preferred.

Benefits