Director, Clinical Quality Improvement-Medicaid Job in Cleveland, OH at Medical Mutual


Medical Mutual Cleveland, OH


Directs Clinical Quality Management Programs for assigned functional areas Healthcare Effectiveness Data and Information Set (HEDIS), Disease Management and Wellness Promotion, Provider Quality, for Medicaid.  Oversees the analysis of the quality of member care and the development and implementation of programs that support continues quality improvement.  Establishes strategic plans, policies and procedures and collaborates with departments Companywide to ensure quality programs meet Company and regulatory requirements.

  • Manages the strategies of the health plan’s clinical quality improvement department, including the activities for HEDIS, Medicaid and Provider Quality.
  • Formulates and executes strategies that improve clinical outcomes and promote wellness for all lines of business, including managing the health plan’s disease management program, as well as vendor oversight.
  • Works with cross disciplinary team to coordinate and perform medical informatics analysis for all lines of business.  Oversees the collection, analysis, reporting and trending of data relative to health- related baselines, outcomes and return on investment of intervention activities.
  • Manages budgets and staffing for assigned area. Ensures there is knowledge of learning and training from all improvement projects, processes and initiatives to provide shared reporting with ODM and contracted Providers.
  • Manages and coordinates the health plan’s clinical quality improvement (CQI) activities among functional areas, monitors the progress of CQI activities against the annual CQI work plan and ensures potential quality of care issues are investigated and resolved.
  • Communicates and monitors quality initiatives, as well as promoting culture changes that support an environment of quality.
  • Performs other duties as assigned.


Education and Experience:

  • Bachelor’s degree in Nursing, Healthcare Administration or related healthcare field required. Master’s degree preferred.
  • 8 years progressive clinical and managed care experience in quality management and quality improvement, 5 years of which are in management and/or leadership capacity driving large scale projects/programs companywide.
  • Significant experience in government programs (Medicare/Medicaid).

Professional Certification(s):

  • Registered Nurse actively licensed in the State of Ohio, preferred
  • Certification in one of the following:


  • Certified Professional in Health Care Quality by the National Association for Healthcare Quality (NAHO)
  • Certified QI Associate by American Society for Quality, and /or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers prior to employment or within six months of date of hire.

Technical Skills and Knowledge:

  • Comprehensive knowledge of managed care tools, components, delivery systems and models; 
  • Comprehesive knowledge of evidenced-based clinical care management, regulatory/accreditation standards and operational management procedures, clinical quality programs, government programs.
  • Advanced oral, written, and interpersonnal communication skills with the ability to present to various audiences includes executive management.
  • Knowledge of and the ability to develop and manage Medicaid program improvement projects, and processes to identify and address health disparities.
  • Knowledge of quality improvement applications, tools and methods.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That’s why we offer an exceptional package that includes:

A Great Place to Work:

  • Top Workplace in Northeast Ohio. Year after year we’ve received this recognition!
  • On-site wellness center at most locations. Enjoy personal trainers, towel service, locker room, weight room, elliptical machines, and a variety of classes!
  • On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locations
  • Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member
  • Business Casual attire

Excellent Benefits and Compensation:

  • Competitive compensation plans
  • Employee bonus program
  • 401(k) with company match and an additional company contribution
  • Excellent medical, dental, vision, and disability insurance

An Investment in You:

  • Career development programs and classes
  • Mentoring and coaching to help you advance
  • Education reimbursement up to $5K per year

About Medical Mutual:

We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We’re the largest health insurer in Ohio and for over 85 years, we’ve been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in the heart of downtown Cleveland and we have multiple offices throughout the state. Join us at one near you!


At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.


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