Note: The job is a remote job and is open to candidates in USA. Blue Zones Health is building a healthcare organization that integrates clinical care, prevention, lifestyle medicine, well-being, and community services. The Quality Manager, Clinical Performance leads operational quality functions including HEDIS, Stars, clinical quality measures, care-gap identification and closure, performance monitoring, provider enablement, and integration of quality intelligence into clinical workflows.
Responsibilities
- Lead operational execution of Blue Zones Health's clinical quality strategy across health plan partnerships, providers, and member populations
- Translate HEDIS, Stars, CMS, health plan, and organizational quality requirements into measurable priorities and actionable clinical workflows
- Establish performance goals, operating rhythms, dashboards, and accountability mechanisms for quality measures
- Identify areas of underperformance and develop targeted improvement strategies in partnership with clinical and operational leaders
- Maintain a clear line of sight between quality initiatives, member outcomes, provider performance, and organizational goals
- Serve as the operational subject-matter expert for applicable HEDIS, Stars, and health plan quality measures
- Maintain measure specifications, eligibility criteria, exclusions, numerator and denominator logic, evidence requirements, and performance targets
- Monitor measure performance throughout the year rather than relying primarily on retrospective year-end gap closure
- Identify measure-specific barriers and implement improvement plans
- Partner with health plans to reconcile quality data, measure performance, supplemental data, and identified gaps
- Ensure operational teams understand what is required to successfully address and document applicable quality measures
- Build and oversee processes for identifying, prioritizing, tracking, and closing member-level care gaps
- Establish workflows that clearly identify which gaps can be addressed by PCPs, which require specialists or external services, and which can be supported through Well-Being Services or Care Management
- Ensure care gaps are surfaced at the appropriate point in the member journey, including before relevant provider encounters whenever possible
- Monitor gap-closure activity and identify barriers preventing members from completing recommended care
- Establish closed-loop processes to verify that completed services are documented and appropriately reflected in quality reporting
- Partner with the Director of Clinical Documentation & Intelligence to integrate quality information into a unified pre-visit clinical view for providers
- Ensure upcoming encounters surface relevant preventive, chronic-care, and quality opportunities alongside other clinically important information
- Prioritize information so providers receive actionable intelligence rather than multiple disconnected lists and alerts
- Monitor whether quality opportunities surfaced before visits are addressed and use results to improve pre-visit workflows
- Partner with Product and technology teams to automate and scale quality intelligence wherever appropriate
- Translate quality measures into practical guidance that providers and practice teams can easily understand and act upon
- Develop provider-facing education, tools, reports, and feedback that support improved quality performance
- Identify provider-specific patterns and opportunities and partner with Provider Success and clinical leadership on targeted improvement efforts
- Help practices incorporate care-gap closure into routine workflows rather than treating quality as a separate periodic initiative
- Support provider onboarding and ongoing education related to BZH quality expectations and clinical quality performance
- Partner with Care Management, Care Coordination, and Well-Being Services to identify quality gaps that can be supported through member outreach, education, scheduling, lifestyle interventions, or community resources
- Establish clear handoffs so member-facing teams understand which gaps require action and what support they can appropriately provide
- Identify barriers such as transportation, social isolation, health literacy, access, or member engagement that may prevent completion of recommended care
- Use WBS capabilities to address underlying barriers while maintaining appropriate boundaries between member engagement and clinical decision-making
- Measure whether WBS-supported interventions contribute to successful completion of recommended care
- Partner with the Director of Clinical Documentation & Intelligence to ensure documentation requirements associated with quality measures are incorporated appropriately into provider education and clinical workflows
- Work with Coding Operations to identify documentation or data-capture deficiencies that prevent completed care from being accurately recognized
- Distinguish between true clinical care gaps and documentation/data gaps so resources are directed appropriately
- Use recurring findings to improve provider education, pre-visit planning, and operational workflows
- Maintain clear separation between quality-measure management, clinical documentation integrity, and coding determinations
- Establish dashboards and reporting that provide timely visibility into quality performance by measure, health plan, provider, population, and market
- Validate quality data and investigate discrepancies among health plan data, clinical records, claims, and internal systems
- Identify populations and providers with the greatest opportunities for improvement and prioritize interventions accordingly
- Analyze performance trends to understand why gaps remain open and whether interventions are producing results
- Provide the VP, Well-Being Services and other leaders with actionable quality insights and recommendations rather than reporting data alone
- Work closely with the VP, Well-Being Services, Medical Directors, Clinical Documentation & Intelligence, Coding, Clinical Management, Care Management, Provider Success, Product, and participating providers
- Establish clear ownership, workflows, and escalation paths for quality opportunities that cross organizational boundaries
- Build repeatable processes that allow the Quality function to scale as membership, provider networks, and health plan relationships grow
- Foster a culture in which quality is understood as part of everyday care delivery and member experience rather than a year-end score
Skills
- Bachelor's degree in nursing, healthcare administration, public health, health information management, or a related healthcare field
- Significant experience in clinical quality, HEDIS, Stars, population health, value-based care, or health plan quality operations
- Strong working knowledge of HEDIS measure specifications, Medicare Stars, CMS quality requirements, and clinical quality measurement
- Experience managing care-gap identification and closure programs
- Demonstrated ability to translate measure specifications into operational workflows
- Experience working with provider practices and clinical teams to improve quality performance
- Strong understanding of preventive care, chronic disease management, and population health
- Strong analytical skills and experience working with clinical, claims, quality, and health plan data
- Demonstrated ability to identify root causes of performance gaps and implement measurable improvement strategies
- Strong project-management, communication, and cross-functional leadership skills
- RN, LPN/LVN, RHIA, RHIT, CPHQ, or other relevant clinical or quality credential
- Certified Professional in Healthcare Quality (CPHQ)
- Medicare Advantage experience
- Experience working within an IPA, risk-bearing medical group, ACO, or delegated entity
- Experience with NCQA requirements and health plan quality audits
- Experience with supplemental data, medical-record review, and quality-data reconciliation
- Experience designing technology-enabled care-gap and pre-visit workflows
- Experience with lifestyle medicine, preventive care, or whole-person care models
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