RN-Quality Clinical Management Advisor
Job Summary 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 1. HEDIS/QRS Market Leadership 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 2. Digital Quality Measurement (dQM) Transformation 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 3. Data & Analytics Enablement Translate performance data into actionable insights for clinical and operational teams Identify automation and process optimization opportunities to reduce manual effort and cost 4. Vendor & Project Management 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 5. Stakeholder & Matrix Leadership 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 3–5 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: Apply To This Job