Director of Health Plan Quality, RN

🕒 Outubro 30

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $150.000 - $210.000 / ano

⏰ Tempo Integral

🔴 Especialista

👔 Diretor

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Montage Health

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

🏥 Saúde

🤝 Sem Fins Lucrativos

Healthcare • Non-profit

Montage Health, uma empresa sem fins lucrativos, é uma coleção — uma montagem — de entidades projetadas para manter as pessoas saudáveis e conectadas. Cuidados preventivos, restauradores, paliativos e coordenados. Muitas partes operando com uma única visão compartilhada.

Descrição

• Lead enterprise STAR strategy to achieve and sustain 4+ STAR ratings • Oversee HEDIS, HOS, and administrative measure performance • Drive cross-functional initiatives to close care gaps and improve clinical outcomes • Align pharmacy, care management, population health, and network strategies to maximize STAR performance • Build relationships across health systems and local providers to maximize participation and engagement • Share in the development of CAHPS strategy and overall member experience performance • Drive improvements across access, communication, care coordination, and member satisfaction • Utilize member feedback, grievances, and appeals data to inform experience transformation • Integrate health equity and culturally competent outreach strategies • Serve as executive owner of RAF clinical strategy and performance • Drive provider documentation accuracy and HCC capture initiatives • Oversee prospective and retrospective programs, including pre-visit planning, chart reviews, and in-home assessments • Ensure RADV audit readiness and regulatory compliance with the Compliance department • Monitor RAF trends and implement targeted improvement strategies • Provide clinical oversight of Appeals and Grievances processes for Medicare and Employer populations • Partner with Customer Service, Utilization Management, and Compliance to ensure a seamless resolution experience • Analyze A&G data, root causes, and trends to identify systemic issues and drive enterprise-wide quality improvement • Integrate clinical A&G insights into CAHPS and member experience strategies • Drive initiatives to improve first-call resolution and enhance member communication • Integrate STAR, CAHPS, RAF, and clinical A&G into a unified enterprise performance framework • Establish KPIs, dashboards, and executive reporting across all domains • Drive continuous improvement and accountability • Align initiatives with population health and value-based care strategies • Ensure compliance with CMS, ERISA, and California regulatory requirements • Plan and prepare for QI/UMC meetings • Participate in NCQA accreditation and audit readiness • Share required data submissions for HEDIS, STAR, risk adjustment, and A&G reporting • Monitor and implement regulatory changes • Partner with providers to improve STAR, CAHPS, RAF, and clinical A&G outcomes • Develop value-based incentive programs tied to quality, experience, and documentation • Deliver actionable provider performance reporting and education • Manage budgets, vendors, and strategic partnerships • Use advanced analytics to identify opportunities and build process-improvement workplans • Drive cross-functional alignment across clinical, operational, and administrative teams

🎯 Requisitos

• 4+ years in health plan quality leadership • 5+ years in senior leadership roles • Minimum of 3 years of clinical experience • Deep experience across STAR ratings and CAHPS (required) • Expertise in CMS STAR methodology, CAHPS, RAF/HCC models • Strong understanding of member experience drivers and complaint resolution processes • Proven ability to drive enterprise performance improvement • Strong background in value-based care and population health • Excellent leadership and stakeholder management skills • Data-driven decision-making expertise • Bachelor’s degree required • Active, unrestricted Registered Nurse (RN) license in any US state is required • CA RN license preferred • Master’s degree (MSN, MPH, MHA, MBA) preferred • Certified Professional in Healthcare Quality (CPHQ) preferred • Certified Risk Adjustment Coder (CRC) or equivalent preferred • Lean / Six Sigma preferred

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