The Director, Clinical Quality & Payor Strategy is responsible for leading strategic initiatives and operational execution across multiple Medicare Advantage and value-based care programs. This role serves as a subject matter expert in quality metrics, electronic health record workflows, and payer partnerships, driving performance improvement and alignment with organizational goals. Collaborates with internal teams, external partners, and payors to optimize care delivery, enhance patient outcomes, and ensure compliance with CMS-aligned models. This includes translating payor requirements into actionable workflows, monitoring performance and visit compliance, and implementing feedback loops that support continuous improvement. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

A Brief Overview
The Director, Clinical Quality & Payor Strategy is responsible for leading strategic initiatives and operational execution across multiple Medicare Advantage and value-based care programs. This role serves as a subject matter expert in quality metrics, electronic health record workflows, and payer partnerships, driving performance improvement and alignment with organizational goals. Collaborates with internal teams, external partners, and payors to optimize care delivery, enhance patient outcomes, and ensure compliance with CMS-aligned models. This includes translating payor requirements into actionable workflows, monitoring performance and visit compliance, and implementing feedback loops that support continuous improvement.

What you will do

• Leads strategic planning and execution of value-based quality initiatives across all payors (CMS, Medicare Advantage, commercial).
• Serves as subject matter expert for internal quality metrics and EHR workflows, providing education, troubleshooting, and optimization support.
• Responsible for achieving quality performance for ACOs, coordinating efforts with payors, Healthchoice, and physicians.
• Develops and manages operational workflows for strategic programs including UHC Fastpass, MdRev, FindHelp, and Aledade, ensuring alignment with organizational goals.
• Develops and drives ongoing management of operational workflows for chronic care management, remote patient monitoring, patient-centered medical home, and transition of care.
• Coordinates with external partners and internal stakeholders to expand services, improve care delivery, and support program growth.
• Facilitates quality governance by organizing committee meetings, preparing agendas, and presenting updates.
• Provides strategic and operational support to Population Health teams, including clinical staff and program managers.
• Monitors compliance with payor-specific visit requirements and documentation standards, ensuring alignment with CMS and contract expectations.
• Partners with Decision Support teams which provide performance tracking and feedback mechanisms to support continuous improvement across clinics and teams to maximize incentives and minimize penalties.
• Ensures internal data feeds are established and active from EHR to all payor platforms in order to streamline quality reporting.
• Collaborates with IT and clinical teams to optimize EHR workflows that support care gap closure and quality reporting.
• Represents the organization in meetings with ACOs and Medicare Advantage payors to drive performance and strategic alignment.

Education/Formal Training Requirements

• Required - Bachelor's Degree Healthcare Administration
• Preferred - Bachelor's Degree Nursing
• Preferred - Bachelor's Degree Public Health
• Preferred - Master's Degree

Work Experience Requirements

• Required - experience in Medicare and Value-Based Programs 7-9 years
• Required - Proven experience in people management and program management
• Preferred - Experience with Epic EHR and population health tools

Knowledge, Skills and Abilities

• Expertise with Medicare Advantage payors, ACO structures, and CMS-aligned quality frameworks.
• Strong understanding of Medicare Advantage, value-based care models, and payor incentive structures.
• Knowledge of compliance standards for patient visits, documentation, and quality reporting.
• Skilled in strategic planning, workflow development, and cross-functional coordination.
• Ability to monitor performance metrics and implement feedback loops for continuous improvement.
• Ability to manage multiple meetings and projects in a fast-paced environment.
• Excellent communication and stakeholder engagement skills across clinical, administrative, and external teams.
• Proficient in interpreting payor contracts and operationalizing requirements into scalable workflows.
• Proficient in managing multi-partner projects and navigating complex healthcare environment.

Supervision Provided by this Position

• Supervises managers, analysts, coordinators, and clinical support staff involved in quality initiatives and operational workflows.
• Provides guidance and training to associates across departments.
• Acts as operational lead for cross-functional teams and external partnerships.

Physical Demands

• Primarily office-based with occasional travel to clinics or partner sites.
• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
• The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.