Performance Improvement & Value-Based Care

• Lead initiatives to improve performance across healthcare quality measures (e.g., CMS, HEDIS) and cost/utilization metrics
• Identify care gaps and variation in performance using clinical, claims, and operational data
• Implement evidence-based strategies to improve outcomes, including care gap closure, chronic disease management, and utilization reduction
• Drive improvements in areas such as readmissions, emergency department utilization, and preventive care

Data Analysis & Reporting

• Analyze healthcare performance data, including quality metrics, utilization trends, and risk adjustment indicators (RAF/HCC), to identify opportunities
• Monitor and report on KPIs related to quality, cost, and patient outcomes
• Translate data into actionable insights for clinical and operational leaders

Provider & Stakeholder Engagement

• Partner with physicians, care teams, and operational leaders to drive performance improvement initiatives
• Support provider education on quality metrics, documentation, and value-based care expectations
• Collaborate with internal teams and external partners, including payers, as needed

Regulatory & Program Alignment

• Support initiatives aligned with CMS programs, including MSSP, Medicare Advantage, and other value-based models
• Stay current on changes in healthcare quality programs and reimbursement models

Operational Execution

• Lead cross-functional initiatives and ensure execution of performance improvement efforts
• Coordinate with care management, analytics, and operations teams
• Track progress and ensure accountability for outcomes

Required Experience

• Minimum 3+ years of experience in healthcare performance improvement, quality improvement, population health, or healthcare operations
• Experience working with healthcare quality metrics (e.g., CMS measures, HEDIS) and/or utilization management
• Demonstrated ability to drive improvements in patient outcomes, quality performance, or cost of care

Skills & Competencies

• Strong understanding of value-based care concepts and healthcare quality measurement
• Experience analyzing healthcare data (clinical, claims, or operational)
• Familiarity with care gap identification, population health strategies, or utilization management
• Exposure to risk adjustment (RAF/HCC) preferred
• Ability to work with and influence clinical stakeholders
• Strong communication, analytical, and problem-solving skills

Education

• Bachelor’s degree in healthcare administration, public health, nursing, or related field required
• Master’s degree preferred

Preferred (Not Required)

• Experience working in an ACO, Medicare Advantage plan, CIN, MSO, or similar environment
• Experience with CMS programs such as MSSP or Star Ratings
• Lean Six Sigma or performance improvement certification