The Manager, Stars and Quality Improvement Programs is responsible for leading and managing the Medicare Advantage quality improvement program. This includes oversight of regulatory and accreditation requirements (CMS, NCQA, HEDIS®, MIPS), quality reporting, audit readiness, and performance improvement initiatives aimed at enhancing member outcomes and provider engagement.

Leading and managing all quality initiatives for the Medicare Advantage line of business, with a strong focus on CMS Star Ratings, HEDIS®, CAHPS®, and HOS performance and driving measurable improvements in medication adherence.

Coordinating and overseeing annual HEDIS® reporting and audits, including roadmap development, data validation, vendor coordination, analysis, and NCQA submission with particular attention to medication-related measures (e.g., adherence for diabetes, hypertension, and cholesterol).

Supervising the MIPS submission process (where applicable to affiliated provider networks), ensuring data integrity and timely reporting.

Managing quality dashboard reporting (HEDIS®, Stars, and other metrics) to support internal strategy and value-based contracting efforts.

Ensuring CMS audit readiness, leading efforts in data validation, monitoring, documentation, and corrective action plans.

Designing and implementing targeted interventions to improve adherence, reduce readmissions, and close care gaps.

Managing and mentoring the Quality and Performance Improvement team, including staff development, performance management, and ongoing training.

Collaborating across clinical, operational, analytics, compliance, and provider teams to identify gaps and drive evidence-based quality improvements.

Developing member and provider education materials to support performance on key quality measures.

Serving as a subject matter expert on CMS, NCQA, HEDIS®, and other regulatory and accreditation standards.

Leading the creation and maintenance of quality policies and procedures; participating in policy committee meetings as needed.

Preparing and presenting executive-level reports and updates to leadership, steering committees, and regulatory bodies.

Oversee vendor relationships for data abstraction, reporting platforms, and engagement tools.

Supporting departmental operations including budget oversight, resource planning, and contract alignment.

Partnering with the QI Director on team structure, new client onboarding, staffing, and implementation strategies.

Demonstrating strong communication, leadership, and problem-solving skills in a fast-paced, evolving healthcare environment.

Leveraging quality incentive structures to identify high-impact opportunities and drive outcomes in the Medicare Advantage population.

Bachelor’s degree in nursing, Public Health, Healthcare Administration, or related field (master’s preferred).

Minimum 7 years of experience in healthcare quality improvement, preferably within managed care or Medicare Advantage.

Strong knowledge of HEDIS®, MIPS, NCQA, CMS Star Ratings, and related quality programs.

Hands-on experience leading the HEDIS® audit process, including collaboration with vendors, oversight of abstraction, and adherence to NCQA audit standards.

Experience in data-driven quality initiatives, quality measure analysis, and performance improvement planning.

Demonstrated success in managing cross-functional teams and leading complex quality projects.

Proven ability to build, coach, and manage a high-performing team.

Exceptional communication, leadership, and organizational skills.

Certification in healthcare quality (e.g., CPHQ) is preferred.

Experience developing provider performance incentives or value-based care models is preferred.

Familiarity with Population Health Management and Social Determinants of Health (SDoH) strategies is preferred.

Experience with member engagement programs to boost CAHPS and HEDIS scores is preferred.

Knowledge of predictive analytics and risk stratification to target population health interventions is preferred.

A track record of leading cross-functional teams to meet or exceed Star Rating goals is preferred.

The base pay range for this role is between $87,000.00 and $90,000.00 per year.

Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.

Comprehensive Medical, Dental, and Vision plans to keep you covered.

401(k) plan includes a 3% employer match to your 6% contribution.

Life and Disability insurance for those "just in case" moments. Additionally, voluntary Life options to keep you and your loved ones protected.

Employee Assistance Program (EAP) for support during tough times.

Paid time off plans to help achieve work-life balance and meet personal goals.

Paid parental leave for new family members.

Various resources dedicated to learning and development to advance your career.

Compensation range paid bi-weekly. Final pay depends on skill set, experience, education, location, and certifications.

Guidehealth is an equal opportunity employer with a strong commitment to diversity, inclusion, and protection of patient and company data.