Director, Health Plan Quality Program Management & Performance (Texas Health Plan)

Accountabilities:

• • Lead and direct the team responsible for health plan quality management and performance improvement activities, ensuring alignment with state, federal, and NCQA requirements.
  • Develop and implement quality program management strategies, including surveys, audits, performance improvement initiatives, and other regulatory activities.
  • Oversee quality program activities and performance management to maintain compliance with applicable health plan contracts, regulations, policies, and quality standards.
  • Represent senior leadership at internal national and regional meetings and serve as a subject matter expert during state-level meetings and quality-related engagements.
  • Oversee the development and completion of effective Performance Improvement Projects (PIPs), using quality improvement methodologies to drive measurable results.
  • Collaborate with analytics and strategic teams to evaluate quality performance management activities, interpret results, and communicate findings to leadership.
  • Maintain quality program structures and processes, including policies and procedures, committee and workgroup governance, document management, reporting, and tracking of key deliverables.
  • Prepare clear written reports and documentation that capture quality activities, member and provider feedback, outcomes, interventions, and remeasurement results.
  • Ensure policies and procedures remain current with evolving state, federal, NCQA, and health plan requirements, including state-specific policy updates.
  • Lead training and education initiatives for quality management and performance staff to ensure understanding of regulatory requirements, workflows, policies, and contractual obligations.
  • Establish ongoing tracking and trending of quality requirements, operational KPIs, process reviews, and gap analyses to identify opportunities for improvement.
  • Apply quality improvement methodologies such as the Plan-Do-Study-Act (PDSA) cycle to support individual, team, and organizational process improvement.
  • Hire, develop, coach, and manage team members while maintaining accountability for team performance and department-specific quality goals.
  • Travel to local or regional project sites approximately 0–50% of the time for same-day business activities and up to 0–20% of the time for overnight travel, depending on health plan and state-specific requirements.

  Requirements:

  • At least 8 years of healthcare experience, including a minimum of 5 years in health plan quality improvement, or an equivalent combination of relevant education and experience.
  • At least 3 years of management or leadership experience.
  • Advanced knowledge of HEDIS and NCQA requirements, standards, and quality program practices.
  • Experience with HEDIS reporting and data collection, CAHPS improvement initiatives, and state quality improvement programs.
  • Experience working with government-sponsored healthcare programs, including Medicaid, Medicare, and Marketplace programs.
  • Understanding of NCQA standards, including experience interpreting requirements and applying them to health plan operations.
  • Experience supporting or leading NCQA accreditation surveys and audits, as well as audits focused on state contracts and regulatory compliance.
  • Experience with Performance Improvement Projects and continuous quality improvement methodologies.
  • Knowledge and experience related to EPSDT and/or Texas Health Steps programs is preferred.
  • Strong data analysis, manipulation, interpretation, reporting, and data-driven decision-making capabilities.
  • Excellent critical-thinking, problem-solving, analytical, organizational, and project management skills.
  • Strong business writing skills and excellent verbal and written communication abilities.
  • Demonstrated ability to implement process improvement initiatives, drive organizational change, and manage significant cross-functional work.
  • Ability to work independently in a fast-paced, deadline-driven environment and effectively operate within a highly matrixed organization.
  • Strong proficiency with Microsoft Office, including Excel, as well as the ability to learn and use new information systems and software.
  • Experience with provider credentialing and subcontractor monitoring is preferred.
  • CPHQ or CHCA certification is preferred.
  • Registered Nurse (RN) qualification is preferred; if licensed, the license must be active and unrestricted in the state of practice.
  • Clinical licensure or certification may be required where mandated by state contract, regulation, business operating model, or applicable licensing requirements.

  Benefits:

  • Competitive compensation and benefits package.
  • Opportunity to lead health plan quality management and performance improvement initiatives with significant organizational and member impact.
  • Leadership responsibility for a specialized quality management and performance team.
  • Exposure to complex state, federal, and NCQA quality programs and regulatory requirements.
  • Cross-functional collaboration with analytics, strategy, clinical, operational, and senior leadership teams.
  • Opportunities to drive data-informed process improvements and continuous quality initiatives.
  • Same-day and overnight travel requirements may vary based on health plan and state-specific needs.
  • Additional healthcare, retirement, paid time off, and other benefit details were not specified in the source job description.