Health Plan Quality RN - Aspire Health

Montage Health•Monterey, CA

6d•Remote

About The Position

The Health Plan Quality RN plays a key role in leading quality and performance improvement initiatives with a primary focus on CMS Medicare Star Ratings. This position is responsible for the identification, development, and implementation of strategic programs that enhance the health plan’s quality performance and regulatory compliance. The Quality RN provides clinical insight into appeals and grievances, oversees potential quality issues (PQIs), and collaborates across internal teams, provider partners, and external vendors to drive continuous improvement in quality, member outcomes, and satisfaction.

Requirements

RN with at least 2 years of health plan experience in the area of Quality (including HEDIS or Stars).
Must have at least 3 years of clinical practice experience.
RN license state of California (unrestricted).

Nice To Haves

MA plan experience preferred.
Experience in project management in healthcare industry.
Experience in health plan quality performance and ratings.
Certifications such as CPHQ, CCM, or PMP.

Responsibilities

Leads the clinical strategic management of Star Ratings and other value-based performance strategies across the medical management division.
Ensures alignment of Stars and quality activities with the organization’s mission and performance goals.
Provides oversight and analysis of all regulatory guidance, rules and data related to Star Ratings to continuously monitor performance and proactively identify risks and barriers.
Provides education, understanding and subject matter expertise regarding the performance measures; highlights the significant impacts of improved ratings with community partners.
Coordinates activities throughout the organization to drive clinical improvements in provider engagement, clinical care, data integrity, customer satisfaction, and communication with members and providers.
Develops, implements, and monitors the Stars Program and tactical work plan through complete understanding of the CMS Medicare Star Ratings.
Tracks and reports progress toward organizational clinical quality goals, ensuring accountability across teams.
Understands organizational clinical and operational activities related to Stars measures and other value-based performance measures to ensure alignment and identifies opportunities for collaboration and continuous improvement.
Facilitates the integration of quality initiatives within daily operations and clinical workflows.
Designs and implements tools as needed to monitor performance.
Conducts clinical measure risk assessments to proactively identify risks to measure performance and creates cross-functional plans to mitigate risks.
Performs preliminary clinical review of appeals and grievances cases with SBAR for CMO to review.
Creates and manages the PQI process, including investigations, provider communication, and peer review preparation.
Ensures alignment with delegated responsibilities by line of business (Medicare Advantage and employer plans).
Uses data to drive initiatives.
When necessary, manages external vendor relationships as they relate to value-based performance activities.
Is highly-organized and collaborative, demonstrating the ability to work independently and meet deadlines.
Reviews and meets ongoing competency requirements of the role to maintain the skills, knowledge and abilities to perform, within scope, role specific functions
Other duties as assigned