Director, Clinical Quality - Medicare Stars

Job Category: Healthcare Services and OperationsJob Description:Your RoleBlue Shield of California is seeking a Director of Clinical Quality - Medicare Stars to lead and advance the organization's Stars and HEDIS strategy, execution, and performance oversight. This role is critical to maintaining and improving Medicare Star Ratings and HEDIS performance by driving initiatives focused on clinical gap closure, quality improvement, health outcomes, and member experience.The Director will oversee the strategic roadmap, operational excellence, and performance oversight of multiple H-Contracts and future Medicare Advantage contracts. The position requires a dynamic leader with deep expertise in Stars, HEDIS, and quality improvement methodologies, as well as the ability to collaborate across clinical and operational functions to enhance performance outcomes and drive systemic changeResponsibilities:Your WorkIn this role, you will:

• Stars & HEDIS Strategy Development: Lead the enterprise-wide Stars and HEDIS improvement strategy, ensuring alignment with the Quality Roadmap and company goals to achieve optimal performance outcomes.
• Clinical Gap Closure & Quality Improvement: Develop and implement targeted interventions that address gaps in care and drive measurable Stars and HEDIS improvements across populations.
• Operational Readiness & Process Optimization: Oversee end-to-end operational processes, ensuring that clinical, data, and outreach teams are fully equipped to execute HEDIS Stars initiatives effectively.
• Stakeholder Engagement & Collaboration: Work across internal teams and external partners, including providers, vendors, and regulatory agencies, to streamline quality initiatives and advance healthcare equity efforts.
• Performance Oversight & Monitoring: Develop and maintain robust reporting dashboards to monitor HEDIS Stars metrics, identify improvement opportunities, and enhance organizational accountability.
• Innovation & Data-Driven Decision Making: Lead test-and-learn initiatives to assess new strategies, leveraging insights from analytics to optimize Stars performance outcomes.
• Member Experience & Engagement: Design and implement strategies that improve the Medicare member experience, fostering higher engagement and satisfaction through quality healthcare interventions.
• Budget & Resource Management: Oversee Stars and HEDIS vendor relationships, operational budgets, and project/program management to drive efficient operations and maximize impact.
• Team Leadership & Development: Lead a team of high-performing professionals, fostering a culture of continuous learning, innovation, and accountability in Stars and HEDIS operations.
• Regulatory Compliance & Industry Leadership: Serve as an SME for Medicare Stars Ratings, HEDIS measures, and quality performance-ensuring compliance with CMS regulations while keeping Blue Shield at the forefront of industry best practices.

Qualifications:Your Knowledge and Experience

• Bachelor's degree required; Master's in Public Health (MPH), Healthcare Administration (MHA), or related field preferred.
• 10+ years of healthcare experience leading large-scale, cross-functional programs focused on quality improvement.
• 6+ years of direct experience managing Stars and HEDIS performance initiatives with proven success in driving improvements.
• Strong ability to interpret complex healthcare data, develop insights, and apply analytics-driven strategies.
• Experience in Medicare Advantage quality programs, CMS requirements, and industry-leading Stars & HEDIS performance improvement techniques.
• Exceptional communication skills, with the ability to engage executive leadership, providers, and stakeholders effectively.
• Strong project management skills, with the ability to navigate tight deadlines, manage competing priorities, and lead strategic initiatives successfully.

About the Team:About Blue Shield of CaliforniaAs of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o Member-facing and approved out-of-state roles remain remote.o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.Equal Employment Opportunity:External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
Apply for the job now! Apply for this job