Health Services, Population Health & Quality Director - Remote in Wisconsin

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The Health Services & Quality Director provides strategic leadership, direction, and oversight for the Health Services, Care Management, Utilization Management, and Clinical Quality functions for the Wisconsin Medicaid health plan. This role is accountable for ensuring high-quality, member-centered care while driving clinical excellence, regulatory compliance, quality performance, and population health outcomes across all Medicaid programs.

Working in a highly matrixed environment, the Director develops and executes integrated clinical and quality strategies that improve member outcomes, support affordability goals, enhance provider performance, and ensure compliance with state, federal, NCQA and accreditation requirements. The role serves as a key leader within the health plan and collaborates closely with executive leadership, state agencies, providers, and enterprise partners to advance the organization's quality, service, and operational objectives.

Populations include Badger Care, SSI, Childless Adults, Family Care and Family Care Partnership.

If you are located in Wisconsin, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Health Services Leadership
  • Provide strategic leadership and oversight for Health Services functions including Care Management, Disease Management, Utilization Management, and Transition of Care programs
  • Lead and develop multidisciplinary clinical teams, ensuring effective performance, engagement, and professional development
  • Establish departmental goals, monitor performance outcomes, and drive continuous improvement initiatives
  • Ensure clinical programs support the health and well-being of statewide Medicaid membership across multiple programs and populations
  • Collaborate with operational and clinical leaders to align health services strategies with organizational priorities and contractual requirements
  • Drive initiatives that improve member experience, access to care, care coordination, quality outcomes, and health equity
• Quality Management & Improvement
  • Provide overall leadership for the health plan's Quality Management Program and Quality Improvement Program
  • Develop and execute comprehensive quality strategies aligned with state, federal, NCQA, and organizational requirements
  • Oversee the development, implementation, monitoring, and evaluation of annual quality work plans and performance improvement initiatives
  • Lead efforts to improve HEDIS, CAHPS, Healthcare Effectiveness Data and Information Set (HEDIS), and other quality performance measures
  • Direct interventions to identify and close gaps in care while improving clinical outcomes and member engagement
  • Establish quality targets and oversee action plans to achieve performance goals
  • Coordinate quality improvement activities across clinical, provider, pharmacy, behavioral health, network, compliance, and member experience functions
• Regulatory & Accreditation Oversight
  • Ensure compliance with Medicaid contractual requirements, state and federal regulations, NCQA standards, and accreditation requirements
  • Oversee the preparation, maintenance, approval, and submission of quality program documentation, including:
    • Quality Program Description
    • Quality Work Plan
    • Annual Evaluation
    • Policies and Procedures
    • Performance Improvement Projects (PIPs)
    • State-required reports and submissions
  • Lead readiness activities and corrective action planning associated with audits, accreditation reviews, EQRO reviews, and state oversight activities
  • Maintain effective quality governance structures, including quality committees and reporting processes
• Stakeholder & Provider Engagement
  • Develop and maintain strong relationships with state regulators, Medicaid agencies, External Quality Review Organizations (EQROs), providers, and community partners
  • Represent the health plan in quality and clinical discussions with state stakeholders and external partners
  • Collaborate with provider organizations to improve quality performance, member outcomes, and regulatory compliance
  • Serve as a strategic advisor and subject matter expert for quality and health services initiatives
  • Contribute to Request for Proposal (RFP) responses and support Medicaid procurement activities, particularly quality and clinical program sections
• Leadership & Organizational Effectiveness
  • Build, mentor, coach, and develop high-performing clinical and quality teams
  • Foster a culture of accountability, collaboration, innovation, and continuous improvement
  • Lead organizational change efforts related to clinical operations and quality performance
  • Utilize data, analytics, and performance insights to identify opportunities and drive strategic decision-making
  • Present clinical and quality performance results to executive leadership, state agencies, and other key stakeholders

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications:

• Current unrestricted Wisconsin RN license, or Wisconsin licensure in Social Work
• Bachelor's degree in Nursing, Healthcare Administration, Public Health, or related field, or equivalent experience
• 8+ years of health plan or managed care experience
• 5+ years of Medicaid managed care experience
• 5+ years of leadership experience managing clinical and non-clinical staff
• 5+ years of clinical practice experience in a hospital, clinic, home health, nursing facility, or related healthcare setting
• Experience in Care Management, Case Management, Disease Management, and/or Utilization Management
• Experience leading quality improvement programs and healthcare quality initiatives
• Experience with HEDIS, NCQA, quality measurement, performance improvement, and regulatory compliance programs
• Demonstrated ability to lead complex initiatives across matrixed organizations
• Solid written, verbal, presentation, and relationship management skills
• Wisconsin residency

Preferred Qualifications:  

• Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or related field
• Certified Professional in Healthcare Quality (CPHQ)
• Certified Case Manager (CCM)
• Experience supporting Wisconsin Medicaid programs and Long-Term Services and Supports (LTSS)
• Experience with state Medicaid agencies, EQROs, accreditation reviews, and governmental audits
• Experience contributing to health plan strategy and affordability initiatives
• Solid change management, process improvement, and project management experience
• Experience developing provider quality improvement partnerships
• Expertise in healthcare quality, population health management, and value-based care strategies
• Demonstrated success influencing executive stakeholders and external regulators

Success Measures:

• Achievement of HEDIS, CAHPS, and state-defined quality targets
• Maintain "first in class" NCQA and STARS performance in the state of Wisconsin
• Improved member health outcomes and care coordination performance
• Successful completion of regulatory audits and accreditation reviews
• Compliance with Medicaid contractual requirements
• Enhanced member and provider satisfaction
• Improved operational efficiency and affordability outcomes
• Development and retention of high-performing clinical and quality teams
• Successful RFP submissions and wins for Family Care and Family Care Partnership

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.  

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $159,300 - $273,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.