Director, HEDIS and Quality Performance

Capital Blue Cross•Harrisburg, PA

About The Position

The Director, HEDIS and Quality Performance, develops and executes the enterprise strategy for HEDIS performance across all lines of business, with particular emphasis on HEDIS measures contributing to Medicare Advantage Star Ratings. Serving as the enterprise subject matter expert and strategic architect, the Director translates CMS and NCQA requirements, Stars methodology, performance data, market intelligence, regulatory changes, and industry practices into strategies that improve clinical quality, member outcomes, provider performance, operational effectiveness, and HEDIS results. The role requires deep expertise in HEDIS measurement, quality improvement, data acquisition and completeness, provider performance, intervention design, audit readiness, and the transition to digital quality measurement. The Director leads through influence in a highly matrixed organization, owns cross-functional HEDIS plans, establishes performance expectations, and drives follow-through and shared accountability. The position oversees a sizeable team of direct and indirect reports, provides matrixed oversight, and builds internal capability through talent development, measure expertise, documentation, cross-training, and sustainable processes. Capital Blue Cross describes a flexible environment that prioritizes health and wellbeing, supports community volunteering, and invests in training and continuing education. The organization’s mission is to improve the health and well-being of its members and the communities in which they live.

Requirements

Minimum 7 years of progressively responsible experience leading HEDIS strategy and improvement in a health plan, with measurable results on measures contributing to Medicare Advantage Star Ratings.
Demonstrated subject matter expertise in medical record retrieval, abstraction, over-read, validation, and audit readiness.
Proven ability to lead complex, cross-functional initiatives in a highly matrixed organization spanning clinical, provider, analytics, pharmacy, and technology functions.
Strong analytical and financial acumen, including the ability to translate quality performance into business and financial implications.
Exceptional executive communication, presentation, and influencing skills.
Advanced knowledge of HEDIS methodology, NCQA requirements, CMS Star Ratings, supplemental data, and measure specifications.
Demonstrated expertise in ECDS reporting, clinical data acquisition and interoperability, including FHIR and standardized clinical terminology, and the transition from hybrid to digital quality measurement.
Master’s degree in healthcare administration, public health, nursing, health sciences, business, health informatics, or a related field.

Nice To Haves

Experience at a consistently high-performing Medicare Advantage plan, including a 4-Star or 5-Star organization, across HMO, PPO, and/or D-SNP products.
Experience integrating HEDIS strategy with CAHPS, medication adherence, provider performance, and risk adjustment.
Experience with HEDIS vendors, NCQA-certified auditors, quality technology platforms, and EHR/clinical data exchange.
Lean, Six Sigma, or related quality improvement certification.
Experience presenting to C-suite or Board-level committees.

Responsibilities

Develop, lead, and own the multi-year enterprise HEDIS strategy, including measures that influence Medicare Advantage Star Ratings, with clear targets, priorities, owners, performance routines, and measurable business outcomes.
Translate CMS and NCQA requirements, Stars methodology, regulatory changes, performance data, and industry trends into actionable priorities.
Oversee the full HEDIS lifecycle, including data acquisition, supplemental data, chart retrieval, abstraction, validation, audit readiness, submission, and transition to digital quality measurement.
Monitor performance across measures, providers, markets, products, and populations; identify gaps, risks, and opportunities; and ensure timely corrective action.
Build and manage a portfolio of HEDIS improvement initiatives, provider performance strategies, and digital quality transformation efforts, defining ownership, milestones, expected impact, cost, timing, and effectiveness measures.
Partner with Provider Network, Analytics, Data/IT, Government Programs, Care Management, Pharmacy, Member Experience, Compliance, vendors, auditors, and consultants to align execution and improve outcomes.
Establish governance, decision rights, escalation paths, and shared accountability across functions responsible for HEDIS results.
Develop forward-looking forecasts, performance reporting, early-warning indicators, and executive-level insights communicating results, risks, opportunities, and recommended actions.
Lead, develop, and retain HEDIS and quality talent; strengthen measure-level expertise, documentation, cross-training, succession planning, and sustainable operating processes.
Foster a culture of focus, transparency, disciplined execution, constructive challenge, and shared accountability for quality performance.
Establish measure-level forecasts, early-warning indicators, and performance routines that distinguish true improvement from data timing, attribution, denominator movement, or retrospective chart retrieval.
Provide strategic oversight of provider, vendor, auditor, and consultant partnerships that materially affect HEDIS performance, including expectations, accountability, and intervention effectiveness.