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Job Description:
Position Summary
The Director of Health Plan Quality is responsible for enterprise leadership of three core performance pillars: STAR Ratings, Member Experience (CAHPS & Engagement), and Risk Adjustment (RAF). This role drives an integrated strategy across these domains to optimize clinical quality, member outcomes, and financial performance for Medicare Advantage and Commercial populations.
In addition, the Director provides the clinical oversight of Appeals and Grievances, ensuring a seamless and member-centric resolution process that directly enhances member experience and satisfaction.
Responsibilities
STAR Ratings Leadership
- 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 in these efforts
Member Experience & CAHPS Leadership
- Share in the development of CAHPS strategy and overall member experience performance.
- In conjunction with marketing and customer service teams, 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.
Risk Adjustment (RAF) Clinical Leadership
- Serve as executive owner of RAF clinical strategy and performance, with support from Finance and Analytics to align risk adjustment, quality, and finance to optimize health plan outcomes.
- Drive provider documentation accuracy and HCC capture initiatives.
- Oversee prospective and retrospective programs (pre-visit planning, chart reviews, in-home assessments).
- In conjunction with the Compliance department, ensure RADV audit readiness and regulatory compliance.
- Monitor RAF trends and implement targeted improvement strategies.
Appeals & Grievances (A&G) Clinical Oversight
- In conjunction with the Operations team, 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 and member-centric 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 to improve satisfaction and reduce repeat complaints.
- With the Customer Service team, drive initiatives to improve first-call resolution and enhance communication with members.
Quality Improvement & Integration
- With partners across all Aspire departments, Integrate STAR, CAHPS, RAF, and clinical A&G into a unified enterprise performance framework.
- Establish KPIs, dashboards, and executive reporting across all domains.
- Drive a culture of continuous improvement and accountability.
- Align initiatives with population health and value-based care strategies.
Regulatory Compliance & Accreditation
- For Quality-related components, ensure compliance with CMS, ERISA, and California regulatory requirements.
- With UM counterpart, plan and prepare for QI/UMC meetings (quarterly).
- Participate in NCQA accreditation and audit readiness when applicable.
- With the support of Aspire’s BI department, share required data submissions (for HEDIS, STAR, risk adjustment, A&G reporting).
- When applicable, monitor and implement regulatory changes across all performance areas.
Provider Engagement & Performance
- 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.
Leadership & Team Management
- Manage budgets, vendors, and strategic partnerships.
- Use advanced analytics to identify opportunities across STAR, CAHPS, RAF, and A&G and build workplans in those areas to support process improvement.
- Drive cross-functional alignment across clinical, operational, and administrative teams.
Knowledge & Skills
- 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
Experience
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)
Education
Bachelor’s degree required; Master’s preferred (MSN, MPH, MHA, MBA)
License/Certifications
Active, unrestricted Registered Nurse (RN) license in any US state is required. CA RN license preferred.
Certified Professional in Healthcare Quality (CPHQ) preferred.
Certified Risk Adjustment Coder (CRC) or equivalent preferred.
Lean / Six Sigma preferred.
Equal Opportunity Employer
Salary: $150,000 - $210,000 (depending on experience)
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Assigned Work Hours:
Full time (remote/hybrid/onsite)
Position Type:
Regular
