- The Director of Quality Strat & Programs is responsible for leading and managing the health system's participation in federal quality programs and external quality rankings, with a strong focus on compliance, performance improvement, and optimization of value-based reimbursement
- This role oversees the design and execution of initiatives that ensure the organization meets or exceeds requirements for CMS quality reporting programs including Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Value-Based Purchasing (VBP), Readmission Reduction Program (HRRP), Hospital-Acquired Condition Reduction Program (HACRP), and external benchmarking and ranking programs such as Leapfrog, U.S. News & World Report, Healthgrades, and Vizient
- The Director works collaboratively with clinical, operational, and executive leaders to embed quality priorities into system strategy and daily practice
- CMS Quality Program Leadership
- Provide strategic oversight for CMS quality programs across the health system, ensuring compliance with reporting requirements and deadlines
- Serve as the system's subject matter expert on CMS quality initiatives, regulations, and evolving requirements
- Translate CMS program requirements into actionable strategies and operational processes across hospitals, ambulatory clinics, and post-acute care settings
- Lead the preparation and submission of required data for CMS quality reporting programs (IQR, OQR, HACRP, HRRP, VBP, etc.)
- External Quality Rankings & Benchmarking
- Oversee reporting and data submissions to external quality and ranking agencies (Commercial Payors, Leapfrog, U.S. News & World Report, Healthgrades, Vizient, etc.)
- Monitor system performance on national rankings and benchmarking programs, identifying opportunities for improvement
- Collaborate with leaders to develop strategies that enhance reputation, star ratings, and public rankings while maintaining transparency and integrity
- Present external ranking outcomes to clinical improvement teams, highlighting risks, opportunities, and areas for strategic focus
- Performance Monitoring & Improvement
- Monitor system performance on CMS star ratings, quality measures, and pay-for-performance programs
- Partner with clinical and operational leaders to develop interventions that improve outcomes in key CMS and ranking program domains
- Analyze trends and identify opportunities to improve performance and protect reimbursement
- Direct teams in the use of reports, scorecards, and performance tools to track progress against CMS and external program measures
- Collaboration & Stakeholder Engagement
- Collaborate with physicians, nurses, quality leaders, and administrative teams to align CMS and ranking program initiatives with system-wide quality and safety goals
- Educate leadership and frontline teams on program requirements and performance impacts
- Serve as liaison with CMS contractors and external ranking agencies regarding quality performance, reporting, and audits
- Data, Reporting & Transparency
- Ensure timely, accurate submission of data for CMS and external ranking programs
- Oversee the preparation of reports and presentations that make CMS and ranking performance data meaningful for leadership, boards, and frontline stakeholders
- Promote transparency of outcomes across the organization to drive accountability and improvement
- Work with analytic teams to evaluate how metrics align across different programs and identify key areas for improvement
- Innovation & Best Practices
- Stay current with CMS regulations, methodologies, and updates to quality and ranking programs
- Recommend and implement best practices that improve CMS and ranking program performance
- Incorporate High Reliability Organization (HRO) principles, Lean/Six Sigma, and evidence-based strategies into program design
- Advance initiatives that address CMS and external quality priorities while promoting equity and patient-centered care
- Additional Duties as Assigned
- Travel: Travel between Operating Units may be required
- Work Type: On-Site employee
MINIMUM REQUIRED
- Bachelor's degree in Public Health, Health Administration, or related field required
- 3+ years of progressive leadership experience in healthcare quality, patient safety, or performance improvement with at least 5 years of experience in related fields
- Direct experience with CMS quality reporting programs (IQR, OQR, VBP, HRRP, HACRP, HCAHPS, Star Ratings) and external rankings (Leapfrog, U.S. News, Healthgrades, Vizient)
- Demonstrated success improving performance in CMS and ranking programs and driving measurable improvements in outcomes
- Strong understanding of healthcare regulatory requirements, pay-for-performance models, and national benchmarking methodologies
PREFERRED QUALIFICATIONS:
- Master's degree in Public Health, Health Administration, or related field required
- 5+ years of progressive leadership experience in healthcare quality, patient safety, or performance improvement
Core Skills & Competencies
- Expertise in CMS quality programs and external rankings
- Strong analytical and problem-solving skills, with the ability to translate data into actionable strategies
- Excellent communication and facilitation skills with executives, clinicians, and frontline staff
- Leadership experience in program management, team facilitation, and cross-functional collaboration
- Commitment to advancing patient safety, equity, and care excellence while protecting reimbursement and enhancing reputation
JOIN OUR TEAM TODAY! Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet® designated ambulatory practice. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.