Director of Health Plan Quality, RN

🔥 8 hours ago

🇺🇸 United States – Remote

💵 $150k - $210k / year

⏰ Full Time

🔴 Lead

👔 Director

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Montage Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

🤝 Non-profit

Healthcare • Non-profit

Montage Health is a family of health organizations situated in Monterey County, designed to keep people healthy and connected. As a nonprofit entity, it provides a continuum of care that encompasses preventive, restorative, palliative, and coordinated services. The Montage Health family includes various organizations such as Aspire Health, Community Hospital of the Monterey Peninsula, MoGo Urgent Care, Montage Health Foundation, Montage Medical Group, Montage Wellness Center, and Ohana, focusing on youth mental healthcare. With a team of 3,000 members, their shared vision is to improve lives by delivering exceptional care and inspiring optimal health.

📋 Description

• 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

🎯 Requirements

• 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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