Clinical Quality Manager

Description Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. The Provider Quality Program Manager II is responsible for coordinating and managing provider quality initiatives designed to improve healthcare quality outcomes and performance measures across Medica's lines of business. This role serves as a key partner between Quality, Clinical Provider Partnerships, Network Management, and operational teams to support provider performance improvement strategies, quality reporting, incentive program administration, and care gap closure efforts. Working with limited supervision, this position manages assigned projects and program components, prepares and analyzes performance data, develops recommendations, and collaborates with internal and external stakeholders to achieve quality objectives, including Medicare Star Ratings, Medicaid quality, HEDIS performance, and value-based care goals. Performs other duties as assigned. Key Accountabilities Provider Quality Program Management Coordinate implementation and ongoing management of provider quality initiatives across assigned provider groups and lines of business Support execution of quality improvement strategies focused on Medicare Stars, Medicaid quality measures, HEDIS, and value-based care programs Monitor program milestones, deliverables, and outcomes to ensure achievement of established goals Provide program management support for cross-functional quality improvement efforts Provider Performance Monitoring and Improvement Synthesize insights to identify improvement opportunities, emerging risks, and priority areas for intervention. Inform and consult on provider performance reports, scorecards, dashboards, and presentations that support organizational and provider decision-making. Serve as a quality subject matter expert to clinical provider partnerships team by interpreting performance results, recommending evidence-based improvement strategies, and informing provider engagement discussions. Monitor trends and key indicators, providing proactive recommendations and escalating significant risks, barriers, or performance concerns to appropriate stakeholders. Evaluate the effectiveness of improvement initiatives and provide ongoing guidance, insights, and best practices to support sustained performance improvement. Provider Incentive Program Administration Support administration of provider quality incentive programs, including performance tracking, reporting, and operational processes Assist with validating and reconciling provider performance results and attribution methodologies Collaborate with finance, network, and quality teams to support accurate incentive calculations and program reporting Maintain documentation and operational procedures related to incentive program administration Quality Data Management and Reporting Partner with Quality Analytics and HEDIS teams to support collection, validation, and reporting of provider quality data. Assist with management of supplemental data submissions and provider data collection activities Support chart retrieval, provider communication, and quality data collection efforts as needed Ensure data integrity and compliance with regulatory and organizational requirements Cross-Functional Collaboration Collaborate with Population Health and Quality Improvement, Clinical Provider Partnerships, Network Management, Value-Based Care Reporting and Analytics, Quality Analytics, HEDIS teams and other Clinical teams to support quality initiatives Participate in implementation of quality-related contractual requirements and operational initiatives Contribute subject matter expertise for quality performance improvement projects and workgroups Support responses to internal requests, audits, and regulatory reporting activities related to provider quality programs Care Gap Closure and Quality Improvement Assist in development and implementation of provider-focused interventions to improve quality outcomes Monitor effectiveness of quality improvement activities and recommend enhancements Support initiatives focused on preventive care, chronic condition management, member experience and member care gap closure Identify best practices and opportunities for continuous improvement Required Qualifications Bachelor's degree or equivalent experience in related field 5+ years of work experience beyond degree in healthcare quality, provider relations, population health, health plan operations, value-based care, program management, or related healthcare field Preferred Qualifications Experience with Medicare Star Ratings, HEDIS, Medicaid quality programs, and/or value-based care initiatives. Experience interacting with provider organizations, clinics, health systems, or provider networks. Experience using healthcare data to drive performance improvement efforts. Program/Project management experience within a health plan, provider organization, or healthcare consulting environment. Clinical background (RN, LPN, or other healthcare licensure) preferred. Working knowledge of healthcare quality improvement principles and performance measurement. Understanding of Medicare, Medicaid, Commercial, and value-based care quality programs. Ability to analyze, interpret, and communicate complex healthcare data and performance metrics. Strong project management and organizational skills. Ability to manage multiple priorities and meet deadlines. Effective written, verbal, and presentation communication skills. Strong relationship-building and stakeholder management capabilities. Proficiency with Microsoft Office applications and healthcare reporting tools. Ability to work independently while collaborating effectively across teams. Demonstrated problem-solving, critical thinking, and continuous improvement mindset. This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN or Madison, WI. The full salary grade for this position is $70,200 - $120,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $70,200 - $105,315. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees. The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law. Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.