Director of Clinical Services

Position Summary

The Director of Clinical Services is responsible for the strategic oversight, development, and execution of Quality Improvement and Risk Adjustment programs within a managed care environment. This role ensures optimal performance in HEDIS, STAR ratings, and Burden of Illness (BOI) accuracy by integrating clinical operations, provider engagement, and data analytics. The Director collaborates cross-functionally to drive quality outcomes, regulatory compliance, and value-based care initiatives.

Key Responsibilities

1. Quality Improvement & HEDIS Oversight

• Lead all quality improvement initiatives to achieve targeted HEDIS measures and CMS STAR ratings performance. 
• Oversee gap closure strategies including preventive care, chronic disease management, and annual wellness visits (AWVs). 
• Monitor and analyze quality performance metrics; implement corrective action plans (CAPs) as needed. 
• Ensure accurate and timely submission of HEDIS data and supplemental data to health plans. 
• Collaborate with health plans on quality audits, validations, and performance improvement plans. 

2. Risk Adjustment (BOI/HCC) Management

• Direct Risk Adjustment programs to ensure accurate capture of Hierarchical Condition Categories (HCC) and appropriate Burden of Illness (BOI) representation. 
• Oversee prospective, concurrent, and retrospective chart review programs. 
• Ensure coding accuracy and compliance with CMS documentation guidelines. 
• Partner with coding vendors and internal teams to optimize coding workflows and productivity. 
• Monitor provider documentation trends and implement targeted education initiatives to support accurate BOI capture. 

3. Provider Engagement & Education

• Develop and lead provider engagement strategies to improve quality and risk adjustment performance. 
• Conduct provider and staff training on documentation, coding, HEDIS measures, and care gap closure. 
• Collaborate with provider groups to integrate workflows into daily practice (e.g., EMR/portal utilization). 
• Support provider performance reporting and scorecard development, including BOI insights. 

4. Clinical Operations & Program Management

• Oversee interdisciplinary teams including Quality, Risk Adjustment, and Coding staff. 
• Develop and implement workflows that align with value-based care models. 
• Ensure integration of clinical data from multiple sources (EMR, claims, hospital data, lab/pharmacy feeds). 
• Lead implementation of clinical programs, including provider portals and care management integration. 

5. Data Analytics & Reporting

• Analyze clinical and operational data to identify trends, gaps, and opportunities. 
• Develop dashboards and reports to track performance (e.g., AWV rates, readmissions, gap closure, BOI trends). 
• Collaborate with IT and analytics teams to enhance data integration and reporting capabilities. 
• Present performance metrics and strategic recommendations to executive leadership. 

6. Regulatory Compliance & Audit Oversight

• Ensure compliance with CMS, NCQA, and state regulatory requirements. 
• Lead internal and external audits (e.g., RADV, HEDIS audits, health plan validations). 
• Develop and monitor corrective action plans in response to audit findings. 
• Maintain policies and procedures aligned with regulatory standards. 

Qualifications

Education

• Registered Nurse (RN), Nurse Practitioner (NP), or other clinical licensure required 
• Master’s degree in Nursing, Healthcare Administration, Public Health, or related field preferred 

Experience

• 7–10 years of progressive leadership experience in managed care, IPA, or health plan environment 
• Strong experience in Quality (HEDIS/STARs) and Risk Adjustment (HCC/BOI) 
• Experience with Medicare Advantage populations highly preferred 
• Proven track record of improving quality scores and BOI performance 

Skills & Competencies

• Deep knowledge of CMS, NCQA, and HEDIS technical specifications 
• Strong understanding of risk adjustment methodologies and coding guidelines 
• Leadership and team management skills with the ability to drive cross-functional initiatives 
• Advanced analytical and problem-solving skills 
• Excellent communication and stakeholder engagement abilities 

Key Performance Indicators (KPIs)

• Achievement of target CMS STAR ratings (e.g., ≥4.5 Stars) 
• Improvement in HEDIS measure performance rates 
• Accuracy and optimization of Burden of Illness (BOI) capture 
• Care gap closure rates (e.g., AWV, preventive screenings) 
• Audit performance (≥95% compliance) 
• Provider engagement and satisfaction

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!