Senior Director, Clinical Quality Governance & Regulatory

Job Summary : This senior leadership role provides strategic oversight for clinical quality, patient safety, risk management, credentialing, peer review, and regulatory compliance. Serving as a key partner to local and national boards, this executive ensures effective governance, quality performance, and accountability across both health plan and care delivery operations. Strategic Leadership & Talent Development: Builds organizational capacity by preparing high-potential talent for advancement and overseeing the recruitment, selection, and development of a highly skilled workforce. Drives continuous learning by establishing educational programs and training standards related to quality and process improvement. Provides a structured framework for performance feedback and coaching, modeling continuous learning and sharing best practices across cross-functional teams. Motivates and empowers teams by aligning cross-functional resource plans with broader business objectives. Acts as a thought leader on industry trends, maintaining organizational alignment with external benchmarks and best practices. Creates opportunities for expanded decision-making across teams and provides decisive guidance when navigating complex organizational challenges. Operational Governance & Strategy: Oversees the operations of multiple units and departments by identifying member needs and managing the allocation and completion of work assignments. Translates high-level business strategy into actionable requirements, ensuring products and services meet member expectations and align with overarching goals. Engages cross-functional business units to champion business plans, assuming responsibility for decision-making and the resolution of escalated issues. Sets and communicates clear objectives, analyzes resource costs and forecasts, and integrates these metrics into comprehensive business plans. Anticipates obstacles impacting performance, addresses gaps through immediate contingency planning, and removes barriers to process improvement. Serves as a trusted subject-matter expert to executive leadership, providing critical consultation to influence the larger organizational strategy. Quality Improvement & Metrics Integration: Directs future quality improvement initiatives, acting as a technical advisor on advanced data-driven principles, problem-solving methods, and Lean/Six-Sigma concepts. Establishes standard methodologies, milestones, and detailed workplans to guide the future direction of organizational process improvement. Oversees the development, collection, and utilization of quality performance metrics to guide policy, consulting with stakeholders to navigate competing objectives. Advocates for the integration of metric utilization into daily workflows, ensuring practical, adaptable, and multidisciplinary standards are met. Evaluates, designs, and implements evidence-based guidelines and programs to reduce clinical variation, optimize patient outcomes, and ensure compliance. Forecasts and revises the standards for utilization and performance reviews using multidisciplinary criteria and a systematic approach to quality improvement. Data Analytics & Reporting: Directs data collection and statistical analyses for quality improvement evaluations, special projects, and multidisciplinary reviews. Establishes long-term plans for the integration of multiple utilization data reporting systems to support evidence-driven improvement. Leads the collection, analysis, and presentation of clinical data to identify trends and outliers, informing high-visibility, long-term strategic goals. Presents and interprets complex quality improvement metric reports for both technical and non-technical audiences, including executive management and external agencies. Risk Management & Patient Safety: Oversees current and future risk management efforts by implementing corrective action plans derived from utilization reviews, clinical record audits, claim denials, and member satisfaction surveys. Utilizes intelligence gathered from root cause analysis, failure mode and effect analysis, near misses, and good catches to establish policies that mitigate future risk. Defines organizational standards for escalating high-risk issues and trends. Monitors, reports, and develops robust mitigation plans for all occurrences that may lead to organizational liability. Oversees comprehensive patient safety management programs, including infection prevention and control. Regulatory Compliance & Policy Development: Serves as the central authority on quality improvement regulations, providing consultation on the interpretation and implementation of current policies and legislation. Translates external regulatory demands into actionable program goals, advising on long-term strategies to address a shifting legislative climate. Ensures process improvement initiatives comply with established internal and external regulatory requirements. Supports continuous survey readiness programs to maintain strict compliance with regulatory standards. Develops strategic, collaborative relationships with government bodies, regulatory agencies, and external quality organizations to advance organizational interests. Forecasts the direction of future educational programs to raise awareness of changes in regulatory requirements and internal system usage. Basic Qualifications & Requirements: Master's degree in Business Administration, Health Care Administration, Nursing, Public Health, or a related field AND a minimum of eight years of experience in health care quality assurance/improvement; OR a Bachelor's degree in a related field AND a minimum of ten years of experience; OR a minimum of thirteen years of directly related experience. Minimum of eight years of experience in a clinical setting, health care administration, or a directly related field. Minimum of six years of experience in a leadership role managing direct reports. Minimum of four years of experience managing operational or project budgets. Minimum of two years of experience utilizing databases, spreadsheets, or continuous quality improvement (CQI) tools. Active Registered Professional Nurse (RN) License in the state of Georgia. Must possess experience as a quality leader within a large healthcare system or hospital setting, including both health plan and clinical experience. Extensive functional experience in credentialing, peer review, patient safety, risk management, and quality governance. Demonstrated experience managing CMS 5-Star ratings, HEDIS metrics, Joint Commission surveys, and NCQA outcomes. Requirement to obtain a Professional in Patient Safety Certificate, Professional Healthcare Quality Certificate, OR Professional in Healthcare Risk Management Certificate within 24 months of hire. #J-18808-Ljbffr MDAEdge