Bachelor's degree or equivalent experience (4 years relevant experience in lieu of degree)
10+ years of experience in HEDIS, CAHPS, or similar quality ratings
6+ years of people management experience
Experience in a California health plan or regulated payer environment
Master's degree in healthcare administration or related field preferred
Experience with quality interventions in preventive care and behavioral health
Familiarity with health equity interventions preferred
Responsibilities
Design and implement enterprise quality programs aligned with strategic goals
Drive quality improvement initiatives using data for HEDIS and CAHPS
Build strategic partnerships across clinical and operational teams
Lead integrated quality initiatives with senior clinical leaders
Manage annual quality program planning and budget development
Utilize data-driven insights for team leadership and staffing plans
Adapt quality strategies to meet evolving business and regulatory needs
Benefits
Hybrid work model with in-office collaboration
Opportunity to lead impactful quality initiatives
Engagement with senior leadership and cross-functional teams
Focus on continuous improvement and professional development
Work within a dynamic and complex healthcare environment
Full Job Description
Job Description
Your Role
The Clinical Quality [Commercial Populations] team is accountable for the organization's quality ratings, preventive and primary care outcomes for Blue Shield of California's Commercial members, and financial risks associated with quality performance. The Director, Clinical Quality will report to the Senior Director, Clinical Quality. In this role you will be accountable for provider network quality performance within the capitated (HMO), fee-for-service (PPO), self-funded and specialty care networks. This includes accountability for designing and executing strategic roadmaps to achieve quality and financial targets, as well as managing a cross-functional, statewide team.
This person is required to live within 50 miles of the Oakland, Rancho Cordova, Woodland Hills or Long Beach office locations.
Responsibilities
Your Work
In this role, you will:
Design, implement, and sustain enterprise quality programs aligned with the Quality Roadmap and Work Plan with specific accountability to drive quality outcomes performance with large medical systems, small physician practices and specialty care teams
Accountable for quality improvement and assurance across current and anticipated member populations, using data to design multi-year HEDIS and CAHPS improvement pathways and change management initiatives within complex systems
Build and maintain strategic partnerships across clinical, operational, technical, and legal teams in order to translate enterprise business strategy into actionable plans that support care teams across the state of California in medical, dental and vision care
Lead collaboration on integrated quality initiatives spanning care delivery, pharmacy, wellness, and technology at all levels, including directly with Chief Medical Officers, Chief Nursing Officers and Medical Directors by demonstrating HEDIS expertise and a variety of influence techniques
Serve in a leadership role with provider partners, ACOs, and enterprise quality governance bodies in order to lead and direct decisions about return-on-investment and provider investment tradeoffs
Own annual quality program planning, evaluation, and budget development with specific accountability for creating successful strategic plans for provider incentives, clinical innovation funding, and penalty risk management with three-year time horizons
Lead teams using data-driven insights, industry best practices, and continuous improvement methodologies including hiring, firing, onboarding, promotion and reward, as well as creating workforce and staffing plans
Adapt quality strategies and program design in response to evolving business and regulatory needs, including close partnership with Senior leadership to align Quality outcomes, technology and artificial intelligence strategies
Qualifications
Your Knowledge and Experience
Requires Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
Requires at least 10 years prior relevant experience achieving outcomes in HEDIS, CAHPS or other publicly reported quality ratings targets
Requires 6 years of prior people management experience with direct responsibility for supervising, coaching, and evaluating direct reports
This person is required to live within 50 miles of the Oakland, Rancho Cordova, Woodland Hills or Long Beach office locations.
Master's degree or equivalent in healthcare administration, public health, or a related field and Lean Six Sigma, or a comparable planning, strategy, program, or improvement certification preferred
Requires experience within a California health plan or comparable regulated payer environment and applying structured change-management methodologies within the California healthcare system
Requires demonstrated experience leading annual or multi-year planning in a complex, matrixed organization
Requires at least 6 years' experience implementing quality interventions for and with preventive care and behavioral health or dental providers
Experience with health equity interventions within clinics, practices or medical groups preferred
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment as well as required travel within the state of California. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of the workday
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.
About the Team
About Blue Shield Of California
Blue Shield of California is a not-for-profit health plan provider that has been providing Californians with access to high-quality healthcare for over 80 years. The company offers a range of health insurance products and services to individuals, families, and employers. Blue Shield of California is committed to improving the health and wellbeing of its members and the communities it serves. The company is also committed to sustainability and has implemented a number of initiatives to reduce its environmental impact.
