Manager of Quality Improvement

Astiva Health; Orange (CA); On-site; USD 120,000 - 165,000; Full time

Job summary

Astiva Health, Inc. in Orange, CA, seeks a Manager of Quality Improvement to oversee Quality Management, Quality Improvement, Risk Adjustment Factors, and Quality Assurance, driving strategies aligned with Astiva’s goals.

You will lead a team, ensure compliance with federal and state requirements, and collaborate with senior management to improve STAR measures, HEDIS, and RAF data through robust reporting and program development.

Qualifications

• 7+ years senior-level Managed Care operations experience.
• Master’s in Public Health or Health Science, or RN/NP/BSN licensure.
• 5+ years QI experience at the plan level preferred.
• Proven ability to build health plan QI programs.
• Must be able to travel for work up to 5% of the time.
• Experience with HMO, Medi-Cal/Medicaid, Medicare, insurance, or relevant government/public service preferred.
• Board reporting and strategic planning experience preferred.
• Experience overseeing delegated medical groups, IPAs, and contracted healthcare entities.

Responsibilities

• Develop strategy, deploy systems, refine workflows, and ensure compliance in Quality Management, QI, and Quality Assurance.
• Maintain compliance with state and federal reporting standards.
• Collaborate with senior management on STR and STARS improvement.
• Lead initiatives to enhance HEDIS, CAHPS, HOS, and other STARS metrics.
• Design and supervise reporting protocols to align deliverables with budgets.
• Review and update QI programs and Medicare policies annually.
• Develop quarterly reporting processes for QI activity progress.
• Ensure adherence to applicable laws and regulations.
• Coordinate with internal departments to uphold QI program policies.
• Prepare reports on performance metrics for medical groups, IPA, and primary care providers.
• Facilitate discussions during Utilization Management/QA Committee and Board meetings.
• Analyze RAF data and conduct audits to improve risk adjustment documentation.
• Recruit and develop staff; manage succession planning.

Skills

Managed Care Operations

QI Experience (Plan Level)

QI Program Building

Healthcare Payer Experience

Board Reporting

Strategic Planning

IPAs/ DMG Oversight

Leadership

Communication

Analytical

Travel flexibility

Education

Master’s in Public Health

RN/NP/BSN licensure

Job description

About Us:

Astiva Health, Inc., based in Orange, CA, is a leading provider of healthcare, offering both Medicare and HMO services. We focus on providing thorough care that’s specially designed for the needs of our diverse community, making sure our services are accessible, affordable, and high quality. We invite you to join us in our mission to improve how healthcare is delivered and to positively impact the lives of those we serve.

SUMMARY:

The Manager of Quality Improvement oversees critical medical management functions including Quality Management, Quality Improvement (QI), Risk Adjustment Factors, and Quality Assurance. This role serves as a key leader, responsible for advancing assigned areas toward enhanced capabilities and operational efficiency in alignment with Astiva’s strategic plan, goals, and objectives.

ESSENTIAL DUTIES AND RESPONSIBILITIES

include the following:

• Responsible for developing strategy, deploying systems, refining workflows, ensuring ongoing operational compliance, and consistently achieving results and metrics related to Quality Management, Quality Improvement (QI), and Quality Assurance.
• Maintains compliance with operational procedures and reporting standards to meet or exceed state and federal requirements.
• Works with senior management to establish a strategic vision for STARS improvement that aligns with Astiva’s business planning process.
• Formulates strategies and carries out tactical plans aimed at enhancing HEDIS, CAHPS, HOS, and other STARS-related measures.
• Designs and supervises monitoring and reporting protocols to keep deliverables and budgets aligned with expectations.
• Annually reviews and updates the QI program, which includes evaluating its effectiveness, updating work plans, and revising Medicare policies and procedures for review and implementation.
• Develops quarterly processes for reporting on QI activity progress.
• Guarantees adherence to all relevant federal, state, and local laws and regulations.
• Partners with internal departments to uphold compliance with the QI program and its policies.
• Prepare reports of medical groups, IPA and primary care providers’ performance on HEIDS, star rating, RAF, and conduct regular discussions during JOM or as needed performance improvement.
• Prepares reports and facilitates discussion and action by the Utilization Management/Quality Assurance Committee and during Board of Directors Meetings.
• Collects, organizes, examines, and presents data regarding risk adjustment factors (RAF).
• Conducts comprehensive, concurrent, and retrospective reviews promptly.
• Develops and applies strategies to strengthen risk adjustment processes for accurate and thorough data collection.
• Performs audits focused on the precision and completeness of risk adjustment documentation.
• Recruits and retains skilled staff members to execute strategic and operational objectives, while managing succession planning and leadership development.
• Maintains regular communication with providers, members, employees, auditors, and regulators as needed.
• Regular and consistent attendance
• Other duties as assigned

Requirements

QUALIFICATION REQUIREMENTS

Candidates must be able to perform all key duties reliably, including maintaining regular attendance. The following requirements reflect the necessary knowledge, skills, and abilities. Reasonable accommodation is available for individuals with disabilities.

EDUCATION and EXPERIENCE

• 7+ years senior-level Managed Care operations experience required
• Master’s in Public Health, Health Science, or RN/NP/BSN licensure
• 5+ years QI experience at the plan level preferred
• Proven ability to build health plan QI programs
• Must be able to travel for work up to 5% of the time
• Experience with HMO, Medi-Cal/Medicaid, Medicare, insurance, or relevant government/public service preferred
• Board reporting and strategic planning experience preferred
• Experience overseeing delegated medical groups, IPAs, and contracted healthcare entities

OTHER SKILLS and ABILITIES:

• Conduct analysis and revise policies across all business lines for Quality and Population Health Management Programs.
• Demonstrate comprehensive expertise in HEDIS, STARS, RAF, HCC, and additional related quality and clinical care measures.
• Possess thorough knowledge of core functions within the health plan environment and effectively address associated challenges.
• Grasp primary objectives and systematically deconstruct them into actionable steps.
• Display exemplary leadership qualities to guide and influence teams.
• Apply advanced problem-solving, analytical, and organizational skills with careful diligence.
• Communicate effectively and professionally in both verbal and written formats.