Director of Health Plan Quality, RN

Montage Health

. Lead enterprise STAR strategy to achieve and sustain 4+ STAR ratings .

Posted 10/30/2026full-timeRemote • United StatesLead💰 $150,000 - $210,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in STAR ratings, CAHPS, and risk adjustment methodologies while driving enterprise performance improvement and ensuring regulatory compliance. Leverages strong leadership and stakeholder management skills to enhance member experience and clinical outcomes.

Highest-signal resume keywords

STAR Ratings ExpertiseCAHPS MethodologyRisk Adjustment Factor (RAF) KnowledgeValue-Based Care ExperienceClinical Leadership

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

HEDIS Performance OversightData-Driven Decision MakingQuality Improvement StrategiesClinical OversightProcess Improvement Workplans

Soft Skills

Stakeholder ManagementLeadershipCommunication

Tools & Technologies

Advanced AnalyticsKPI Dashboards

Certifications & Qualifications

Registered Nurse (RN) LicenseCertified Professional in Healthcare Quality (CPHQ)Certified Risk Adjustment Coder (CRC)

Industry Keywords

Population HealthHealth EquityCMS ComplianceERISA RegulationsNCQA Accreditation

About the role

Key responsibilities & impact

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
Align pharmacy, care management, population health, and network strategies to maximize STAR performance
Build relationships across health systems and local providers to maximize participation and engagement
Share in the development of CAHPS strategy and overall member experience performance
Drive improvements across access, communication, care coordination, and member satisfaction
Utilize member feedback, grievances, and appeals data to inform experience transformation
Integrate health equity and culturally competent outreach strategies
Serve as executive owner of RAF clinical strategy and performance
Drive provider documentation accuracy and HCC capture initiatives
Oversee prospective and retrospective programs, including pre-visit planning, chart reviews, and in-home assessments
Ensure RADV audit readiness and regulatory compliance with the Compliance department
Monitor RAF trends and implement targeted improvement strategies
Provide clinical oversight of Appeals and Grievances processes for Medicare and Employer populations
Partner with Customer Service, Utilization Management, and Compliance to ensure a seamless resolution experience
Analyze A&G data, root causes, and trends to identify systemic issues and drive enterprise-wide quality improvement
Integrate clinical A&G insights into CAHPS and member experience strategies
Drive initiatives to improve first-call resolution and enhance member communication
Integrate STAR, CAHPS, RAF, and clinical A&G into a unified enterprise performance framework
Establish KPIs, dashboards, and executive reporting across all domains
Drive continuous improvement and accountability
Align initiatives with population health and value-based care strategies
Ensure compliance with CMS, ERISA, and California regulatory requirements
Plan and prepare for QI/UMC meetings
Participate in NCQA accreditation and audit readiness
Share required data submissions for HEDIS, STAR, risk adjustment, and A&G reporting
Monitor and implement regulatory changes
Partner with providers to improve STAR, CAHPS, RAF, and clinical A&G outcomes
Develop value-based incentive programs tied to quality, experience, and documentation
Deliver actionable provider performance reporting and education
Manage budgets, vendors, and strategic partnerships
Use advanced analytics to identify opportunities and build process-improvement workplans
Drive cross-functional alignment across clinical, operational, and administrative teams

Requirements

What you’ll need

4+ years in health plan quality leadership
5+ years in senior leadership roles
Minimum of 3 years of clinical experience
Deep experience across STAR ratings and CAHPS (required)
Expertise in CMS STAR methodology, CAHPS, 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
Bachelor’s degree required
Active, unrestricted Registered Nurse (RN) license in any US state is required
CA RN license preferred
Master’s degree (MSN, MPH, MHA, MBA) preferred
Certified Professional in Healthcare Quality (CPHQ) preferred
Certified Risk Adjustment Coder (CRC) or equivalent preferred
Lean / Six Sigma preferred