RN-Quality Clinical Management Advisor

Job Title

Leads clinical quality measurement and improvement activities, ensuring successful execution of Healthcare Effectiveness Data and Information Set (HEDIS) while advancing the transition to digital quality measurement (dQM). Accountable for market performance, regulatory compliance, vendor management, and the modernization of data acquisition, measurement, and reporting capabilities.

Scope & Impact

Primary market lead for end-to-end HEDIS execution and performance outcomes

Drives measurable improvement in quality metrics and Stars/HEDIS performance

Leads adoption of digital quality measurement capabilities, including EHR-enabled data capture and interoperability

Influences cross-functional teams (clinical, IT, provider, vendor, customer facing, and enterprise stakeholders)

Manages vendors, budget, and operational efficiency for quality programs

Key Responsibilities

Direct annual HEDIS production, submission, and audit readiness

Own market-level performance strategy, identifying and closing care gaps

Lead state-specific submissions and regulatory requirements

Serve as SME on HEDIS specifications, abstraction, clinical data acquisition, and reporting

Lead transition from hybrid/manual to digital quality measurement

Partner with IT and vendors to enhance clinical data acquisition (EHR, HIE, FHIR-enabled sources)

Modernize workflows, clinical data acquisition, and reporting

Translate performance data into actionable insights for clinical and operational teams

Identify automation and process optimization opportunities to reduce manual effort and cost

Manage vendor relationships, deliverables, and performance

Oversee contractor resources and ensure accountability to timelines and outcomes

Manage budget and drive operational efficiencies

Lead cross-market and national initiatives

Partner with Market Medical Executives, Provider Experience, Contracting, IT, Legal, and Clinical teams

Support client-facing engagements and performance discussions

Represent organization in external quality collaborations and initiatives

Required Qualifications

Bachelor's degree; Registered Nurse (RN) required

35 years HEDIS measurement and reporting experience

5+ years clinical quality/performance improvement experience

Strong knowledge of NCQA, and regulatory requirements

Experience in managed care or healthcare delivery environment

Demonstrated project management, analytical, and communication skills

Preferred Qualifications

Master's degree (Nursing, Public Health, Informatics, or related field)

Experience with digital quality measurement and data modernization initiatives

Proficiency with EHR Systems and MS Excel

Knowledge of clinical data standards and interoperability (e.g., FHIR, HL7), and Tableau, PowerBI, and healthcare interoperability solutions

Vendor management experience

Core Competencies

Quality Measurement Expertise (HEDIS, gap closure, audit readiness)

Digital & Data Acumen (EHR data, interoperability, automation)

Strategic & Analytical Thinking (insight generation, ROI focus)

Matrix Leadership & Influence (cross-functional alignment)

Operational Execution (timelines, budget, vendor performance)

Success Measures

On-time, accurate HEDIS/QRS submission and strong audit outcomes

Improvement in key quality metrics and market performance rankings

Increased digital data capture and reduced reliance on manual abstraction

Demonstrated operational efficiencies and cost savings

Strong stakeholder and client satisfaction

Work Conditions

Travel: <10%

Work Arrangement: Remote