Director of Health Plan Quality (RN) - Aspire Health

Montage Health

12d•$150,000 - $210,000

About The Position

The Director of Health Plan Quality provides enterprise leadership for STAR Ratings, member experience (CAHPS and engagement), and risk adjustment (RAF), integrating these areas to improve clinical quality, member outcomes, and financial performance for Medicare Advantage and Commercial populations. The role also provides clinical oversight of Appeals and Grievances for Medicare and Employer populations, with a focus on member-centered resolution and improved satisfaction. The Director leads quality strategy and performance improvement, establishes KPIs and executive reporting, supports regulatory compliance and accreditation, and partners with providers and internal teams across clinical, operational, administrative, finance, analytics, marketing, customer service, compliance, and population health functions. The role manages budgets, vendors, and strategic partnerships and drives cross-functional accountability and continuous improvement.

Requirements

At least 4 years of health plan quality leadership experience.
At least 5 years in senior leadership roles.
At least 3 years of clinical experience.
Deep experience across STAR ratings and CAHPS.
Bachelor’s degree required.
Active, unrestricted Registered Nurse (RN) license in any US state required.
Expertise in CMS STAR methodology, CAHPS, and 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.

Nice To Haves

Master’s degree, such as MSN, MPH, MHA, or MBA.
California RN license.
Certified Professional in Healthcare Quality (CPHQ).
Certified Risk Adjustment Coder (CRC) or equivalent.
Lean or Six Sigma qualification.

Responsibilities

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, aligning pharmacy, care management, population health, and network strategies.
Build relationships with health systems and local providers to maximize participation and engagement in quality initiatives.
Share in developing CAHPS strategy and overall member experience performance; work with marketing and customer service to improve access, communication, care coordination, and member satisfaction.
Use member feedback, grievances, and appeals data to inform member experience improvements, including health equity and culturally competent outreach strategies.
Serve as executive owner of RAF clinical strategy and performance, aligning risk adjustment, quality, and finance with support from Finance and Analytics.
Drive provider documentation accuracy and HCC capture initiatives; oversee prospective and retrospective programs, including pre-visit planning, chart reviews, and in-home assessments.
Work with Compliance to ensure RADV audit readiness and regulatory compliance; monitor RAF trends and implement targeted improvement strategies.
Provide clinical oversight of Appeals and Grievances processes for Medicare and Employer populations in conjunction with Operations.
Partner with Customer Service, Utilization Management, and Compliance to ensure seamless, member-centric resolutions; analyze A&G data, root causes, and trends to identify systemic issues and drive quality improvement.
Integrate clinical A&G insights into CAHPS and member experience strategies, and work with Customer Service to improve first-call resolution and member communications.
Integrate STAR, CAHPS, RAF, and clinical A&G into a unified enterprise performance framework; establish KPIs, dashboards, and executive reporting.
Drive continuous improvement and accountability, aligning initiatives with population health and value-based care strategies.
Ensure compliance for quality-related components with CMS, ERISA, and California regulatory requirements; plan and prepare for quarterly QI/UMC meetings with the UM counterpart.
Participate in NCQA accreditation and audit readiness when applicable; share required HEDIS, STAR, risk adjustment, and A&G data submissions with support from Aspire’s BI department; monitor and implement regulatory changes when applicable.
Partner with providers to improve STAR, CAHPS, RAF, and clinical A&G outcomes; develop value-based incentives and deliver provider performance reporting and education.
Manage budgets, vendors, and strategic partnerships; use advanced analytics to identify opportunities and develop workplans for process improvement.
Drive cross-functional alignment across clinical, operational, and administrative teams.