Manager of Health Plan Quality

Summary / Objective: 
The Manager of Health Plan Quality is responsible for leading the strategy, implementation, and performance optimization of HEDIS (Healthcare Effectiveness Data and Information Set) and CMS Star Ratings programs for a Medicare Advantage Organization (MAO). This role drives quality improvement initiatives, ensures regulatory compliance, and partners cross-functionally to improve clinical outcomes, member experience, and overall Star Ratings performance.  This position requires deep expertise in Medicare Advantage Stars measures, HEDIS abstraction and reporting, and continuous quality improvement practices.Essential Functions: 
HEDIS Program Management
•    Lead annual HEDIS project planning, execution, and reporting in compliance with NCQA standards.
•    Oversee hybrid and administrative data collection processes, including medical record review and abstraction vendors.
•    Ensure data accuracy, completeness, and audit readiness for NCQA HEDIS Compliance Audit.
•    Partner with IT and analytics teams to validate measure logic and data integrity.
•    Support implementation of required tools and platforms
Stars Strategy & Performance
•    Develop and execute a multi-year Stars strategy to achieve 4 Star performance. 
•    Monitor and analyze CMS Star Ratings, identifying performance gaps and opportunities. 
•    Lead measure-level performance improvement initiatives across domains: 
o       Clinical Quality
o       Member Experience (CAHPS)
o       Pharmacy Quality
o       Operational measures
•    Track performance against benchmarks and implement rapid-cycle interventions.
Quality Improvement Initiatives
•    Design and implement provider and member engagement strategies to close care gaps.
•    Collaborate with network providers on value-based care initiatives and performance improvement plans.
•    Support population health programs targeting chronic disease management and preventive care.
Regulatory Compliance
•    Ensure alignment with CMS, NCQA, and state regulatory requirements.
•    Maintain readiness for CMS audits, program validations, and reporting deadlines.
•    Stay current with evolving regulations impacting MA Stars and HEDIS specifications.
•    Cross-Functional Collaboration – Partner with various groups including:
o      Provider network teams on engagement and incentive alignment
o      Pharmacy teams for medication adherence measures
o      Member engagement/marketing for outreach campaigns
o      Data analytics teams for reporting and insights
•    Act as subject matter expert (SME) for HEDIS and Stars program performance.
Analytics & Reporting
•    Develop dashboards and reports to track performance trends and outcomes.
•    Translate complex data into actionable insights for leadership.
•    Present results, risks, and improvement plans to executive stakeholders.Vendor Management
•    Oversee performance and deliverables of HEDIS abstraction and Stars consulting vendors.
•    Ensure vendor compliance with contractual obligations and timelines.
Team Leadership
•    Manage and mentor analysts or specialists supporting HEDIS and Stars functions.
•    Foster a performance-driven, collaborative team culture.

Knowledge, Skills & Abilities:
•    Analytical and problem-solving skills
•    Strong written and verbal communication
•    Ability to work independently and manage multiple deadlines
•    Collaborative mindset and customer service orientation
•    Detail oriented with a focus on accuracy and compliance.
•    Understanding of Accountable Care Organization and the operations of a Clinically Integrated Network.
•    Ability to navigate conflict and ambiguity with positivity.