Director of Health Plan Quality, RN

This is a fully remote position, open to applicants in United States.

📋 Description

• Lead the enterprise STAR strategy to achieve and maintain ratings of 4 or higher.

• Supervise the performance of HEDIS, HOS, and administrative measures.

• Propel cross-functional initiatives aimed at closing care gaps and enhancing clinical outcomes.

• Align strategies for pharmacy, care management, population health, and network to optimize STAR performance.

• Cultivate relationships with health systems and local providers to enhance participation and engagement.

• Contribute to the development of the CAHPS strategy and overall member experience performance.

• Enhance improvements in access, communication, care coordination, and member satisfaction.

• Utilize member feedback, grievances, and appeals data to guide experience transformation.

• Integrate health equity and culturally competent outreach strategies.

• Act as the executive owner of the RAF clinical strategy and its performance.

• Promote accuracy in provider documentation and initiatives for HCC capture.

• Oversee both prospective and retrospective programs, including pre-visit planning, chart reviews, and in-home assessments.

• Ensure readiness for RADV audits and compliance with regulatory requirements in collaboration with the Compliance department.

• Monitor RAF trends and execute targeted improvement strategies.

• Provide clinical oversight for Appeals and Grievances processes for Medicare and Employer populations.

• Collaborate with Customer Service, Utilization Management, and Compliance to ensure a smooth resolution experience.

• Analyze A&G data, root causes, and trends to identify systemic issues and drive quality improvements across the enterprise.

• Incorporate clinical A&G insights into CAHPS and member experience strategies.

• Initiate efforts to enhance first-call resolution and improve member communication.

• Merge STAR, CAHPS, RAF, and clinical A&G into a cohesive enterprise performance framework.

• Establish KPIs, dashboards, and executive reporting across all areas.

• Drive continuous improvement and foster accountability.

• Align initiatives with strategies for population health and value-based care.

• Ensure compliance with CMS, ERISA, and California regulatory standards.

• Plan and prepare for QI/UMC meetings.

• Engage in NCQA accreditation and audit preparation.

• Share necessary data submissions for HEDIS, STAR, risk adjustment, and A&G reporting.

• Monitor and implement changes in regulations.

• Collaborate with providers to enhance STAR, CAHPS, RAF, and clinical A&G outcomes.

• Design value-based incentive programs linked to quality, experience, and documentation.

• Provide actionable reporting and education on provider performance.

• Manage budgets, vendors, and strategic partnerships.

• Leverage advanced analytics to identify opportunities and formulate process-improvement work plans.

• Foster cross-functional alignment among clinical, operational, and administrative teams.

⛳️ Requirements

• A minimum of 4 years in health plan quality leadership.

• At least 5 years in senior leadership positions.

• A minimum of 3 years of clinical experience.

• Extensive experience with STAR ratings and CAHPS (mandatory).

• Proficient in CMS STAR methodology, CAHPS, and RAF/HCC models.

• Strong understanding of factors influencing member experience and complaint resolution processes.

• Proven track record in driving performance improvement across the enterprise.

• Solid background in value-based care and population health.

• Exceptional leadership and stakeholder management capabilities.

• Expertise in data-driven decision-making.

• Bachelor’s degree is required.

• An active, unrestricted Registered Nurse (RN) license in any US state is mandatory.

• Preferred CA RN license.

• A Master’s degree (MSN, MPH, MHA, MBA) is preferred.

• Certified Professional in Healthcare Quality (CPHQ) is preferred.

• Certification as a Risk Adjustment Coder (CRC) or equivalent is preferred.

• Lean / Six Sigma certification is preferred.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• Retirement plans with company matching.

• Professional development opportunities and continuing education support.

• Flexible work arrangements and a supportive work environment.