Director, Clinical Quality (Medicare Stars)

Your Role 

The Director of Clinical Quality - Medicare Stars reports to the Senior Director of Clinical Quality and leads the organization’s Medicare Stars HEDIS strategy, execution, and performance oversight. This role is critical to maintaining and improving Medicare Star Ratings and HEDIS performance by driving initiatives focused on clinical gap closure, quality improvement, health outcomes, and member experience.

The Director will oversee the clinical quality strategic roadmap, operational excellence, and performance oversight of multiple H-Contracts and future Medicare Advantage contracts. The position requires a dynamic leader with deep expertise in Stars, HEDIS, and quality improvement methodologies, as well as the ability to collaborate across clinical and operational functions to enhance performance outcomes and drive systemic change.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Lead the enterprise-wide Medicare Stars HEDIS improvement strategy, ensuring alignment with the Quality Roadmap and company goals to achieve optimal performance outcomes.
• Develop and implement targeted interventions that address gaps in care and drive measurable Stars and HEDIS improvements across populations.
• Oversee end-to-end operational processes, ensuring that clinical, data, and outreach teams are fully equipped to execute HEDIS Stars initiatives effectively.
• Work across internal teams and external partners, including providers, vendors, and regulatory agencies, to streamline quality initiatives and advance healthcare equity efforts.
• and maintain robust reporting dashboards to monitor HEDIS Stars metrics, identify improvement opportunities, and enhance organizational accountability.
• Lead test-and-learn initiatives to assess new strategies, leveraging insights from analytics to optimize Stars performance outcomes.
• Design and implement strategies that improve the Medicare member experience, fostering higher engagement and satisfaction through quality healthcare interventions.
• Oversee Stars and HEDIS vendor relationships, operational budgets, and project/program management to drive efficient operations and maximize impact.
• Lead a team of high-performing professionals, fostering a culture of continuous learning, innovation, and accountability in Stars and HEDIS operations.
• Serve as an SME for Medicare Stars Ratings, HEDIS measures, and quality performance—ensuring compliance with CMS regulations while keeping Blue Shield at the forefront of industry best practices.

Your Knowledge and Experience

• Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
• Master’s in Public Health (MPH), Healthcare Administration (MHA), or related field is preferred.
• 10 years of healthcare experience leading large-scale, cross-functional programs focused on quality improvement.
• 6 years of prior people management experience with direct responsibility for supervising, coaching, and evaluating direct reports
• 6 years of direct experience managing Stars and HEDIS performance initiatives with proven success in driving improvements.
• Strong ability to interpret complex healthcare data, develop insights, and apply analytics-driven strategies.
• Experience in Medicare Advantage quality programs, CMS requirements, and industry-leading Stars & HEDIS performance improvement techniques.
• Exceptional communication skills, with the ability to engage executive leadership, providers, and stakeholders effectively.
• Strong project management skills, with the ability to navigate tight deadlines, manage competing priorities, and lead strategic initiatives successfully.

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.