Quality Improvement Manager

Astiva Health, Inc; California (MO); On-site; USD 120,000 - 150,000; Full time

Job summary

Astiva Health, Inc., based in Orange, CA, seeks a Manager of Quality Improvement to oversee Quality Management, Quality Improvement, Risk Adjustment Factors, and Quality Assurance. This leadership role advances STARS-related initiatives and aligns with Astiva’s strategic plan.

You will develop strategies, deploy systems, and monitor metrics, ensuring compliance with federal and state requirements while collaborating with internal teams and providers to drive data-driven improvements in HEDIS,

Qualifications

• 7+ years senior-level Managed Care operations experience.
• 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.

Responsibilities

• Develops strategy, deploys systems, refines workflows, ensuring ongoing compliance and achieving results in Quality Management, Quality Improvement (QI), and Quality Assurance.
• Maintains compliance with procedures and reporting standards to meet state and federal requirements.
• Leads strategic vision for STARS improvement aligned with Astiva’s planning process.
• Implements strategies for improving HEDIS, CAHPS, HOS, and STARS-related measures.
• Designs monitoring and reporting protocols to keep deliverables and budgets aligned with expectations.
• Annually reviews and updates the QI program and Medicare policies and procedures.
• Prepares reports on QI activity progress and conducts discussions during governance meetings.
• Gathers data on RAF and risk adjustment factors and conducts QA audits.

Skills

Leadership

Quality Improvement

Data analysis

Communication

Education

Master’s in Public Health

RN/NP/BSN licensure

7+ years Managed Care operations experience

5+ years QI experience

Job description

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

• 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.
• Demonstrates regular and dependable attendance.

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.