Quality Performance Lead - Medicare / ACO

Humana

21h • $104,000 - $143,000 • Remote

About The Position

Become a part of our caring community and help us put health first CenterWell is seeking a Medicare Quality Lead to support its original Medicare business and Accountable Care Organization (ACO). Under general direction and supervision from the ACO Director, this role will be responsible for strategy, execution, and performance of all quality measurement and reporting activities. Quality Lead will ensure successful performance across CMS APMs and quality programs such as MSSP, ACO REACH, LEAD, MIPS and others. Additionally, this role requires a deep understanding of the Medicare APP / QPP program including eCQM, Medicare CQM, and MIPS reporting. Leads and directs continuous quality improvement initiatives and works with various stakeholders on measure-level accountability and gap closure - partnering specifically with clinical, analytics, operations, and provider engagement teams to optimize outcomes and shared savings. Lastly, manage relationship with third-party quality registry to ensure completeness with data collection, submission, reporting, and monitoring.

Requirements

• Bachelor’s degree required; master’s degree preferred (MPH, MHA, MBA, or related)
• 5+ years of experience in healthcare quality, population health, or value-based care
• Direct experience with CMS ACO quality programs (MSSP and / or ACO REACH) strongly preferred)
• Deep knowledge of CMS quality measures, specifications, and quality reporting (eCQM / CQM)
• Familiarity with EMR systems and quality reporting workflows
• Strong understanding of value-based payment models and shared savings mechanics
• Familiarity with healthcare industry including value-based care, health plans, health systems, Medicare, accountable care, population health, medical group management / practice management, or Management Service Organizations (MSOs)

Nice To Haves

• Nursing licensure preferred (RN, LPN)

Responsibilities

• Quality Strategy & Program Leadership: Own quality strategy for the ACO; align to CMS program requirements and organizational goals
• Translate CMS quality measures into actionable clinical and operational workflows
• Lead annual quality planning, goal setting, and performance forecasting
• Serve as the main internal subject matter expert on ACO quality programs. CMS Quality Reporting & Compliance:
• Oversee quality reporting for MSSP (eCQMs, CAHPS, administrative measures)
• Oversee quality reporting for ACO REACH / LEAD (quality withhold / earn-back accountability and performance measures)
• Oversee MIPS / APM quality reporting for non-qualified APM / ACO participants
• Ensure compliance with CMS technical specifications, submission deadlines, and audit requirements
• Coordinate w/ quality registry to ensure accurate on-time submission; validate output
• Lead CMS audits, data validation, and corrective action plans Performance Monitoring & KPIs
• Monitor measure performance at ACO, practice, and patient levels
• Develop and monitor KPIs
• Work closely with operations and provider engagement teams to identify and close gaps
• Interpret performance trends and communicate insights to executive leadership Clinical Quality Improvement:
• Design and implement quality improvement initiatives (i.e. preventive care, chronic disease management, care transitions) - align clinical programs / interventions to measures that materially impact performance
• Collaborate with care management, population health and informatics teams embed quality into workflows
• Use data-driven interventions to close care gaps and improve patient outcomes Provider Engagement & Education:
• Educate providers and provider engagement teams on quality measures and documentation requirements
• Surface performance results and improvement opportunities
• Provide performance updates and training sessions, as needed
• Assure that standards of practice and policies are compliant with the ACO contractual requirements and other contractual and regulatory guidelines and standards
• Ensure ACO programs are administered and configured and loaded properly; oversee key operational processes; identify opportunities for performance improvement, and provide regular performance updates
• Oversee ACO wholly owned participant provider segment including key processes, programs, and performance; liaise with market teams
• Manage ACO governance process, including the Center Well ACO Board
• Provide ACO strategy and planning support; coordinate closely with M&A team on ACO integration planning for acquired provider groups
• Prepare executive level presentations that highlight business performance and opportunities
• Develop, prepare, and interpret reports.
• Write basic SQL queries to pull data and build reports.
• Coordinate with Business Intelligence Lead and support ad hoc reporting.
• Develop basic modeling and business case analysis, work closely with Finance and Data teams
• Coordinate with ACO Lead overseeing the IPA / Affiliate business segment
• Adept at forming strong relationships with diverse teams and personalities through effective trust building and collaboration; highly organized, demonstrated ability to show meticulous attention to detail
• Use your skills to make an impact

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level