JOB PURPOSE:

The purpose of this role is to provide strategic leadership for Medicare Advantage quality performance, risk adjustment, coding integrity and reimbursement optimization across PruittHealth Premier health plans and VBC provider initiatives. Integrates MOC, HEDIS, Star Ratings, utilization, and HCC/RAF into actionable provider-level strategies improving outcomes, reducing hospitalizations, and enhancing revenue integrity.

KEY RESPONSIBILITIES:

This position is considered an office position with minor travel required. The following defines the responsibilities of the Director of Quality and Revenue Integrity:

1. Actively track a wide range of quality metrics including Model of Care Metrics, Hospitalization metrics, HCC/RAF Data, HEDIS/Star Ratings metrics and CMS Display measure metrics for all plans/plan types.

2. Provide focused, ongoing capacity to identify opportunities for improvement in a systematic and proactive manner. Translate into provider-specific actionable improvements to send directly to providers and monitor improvement.

3. Analyze data routinely and ongoing to identify risk areas early and assist with performance improvement plan development to mitigate risks.

4. Model of Care (MOC) Metric Monitoring - responsible for the continuous monitoring and analysis of CMS MOC performance metrics and support early identification of trends, gaps, or documentation risks that could result in corrective action plans or adverse CMS Program audit findings.

5. HEDIS® and Star Ratings Data Analysis - serve as a centralized position for managing and interpreting HEDIS® and Star Ratings data, including:

a. Validation and reconciliation of data from claims, EHR, supplemental feeds, and vendor source

b. Ongoing tracking of performance against Star cut points and internal target

c. Identification of measure level drivers for underperformance or improvement

d. Support for annual HEDIS submissions and mid-year improvement effort

e. Assist with HEDIS/Star related performance improvement projects.

6. Hospitalization, ADK, and Utilization Performance Improvement

a. Monitoring SIP/SNF utilization, and ADK trends at the plan, facility, and provider level

b. Stratifying utilization data to identify outlier facilities, high risk populations, or repeat admission pattern

c. Supporting analysis for existing or future Performance Improvement Projects (PIPs) focused on inpatient utilization or transitions of care

d. Translating utilization data into clear, provider level insight

7. HCC / RAF Data Oversight and Coding Gap Closure by acting as a functional link between coding data, clinical documentation, and provider behavior.

a. Identifying suspected, missing, or under documented HCCs based on claims, encounter, and clinical data

b. Supporting analysis of coding gaps by provider or facility

c. Monitoring year over year persistence of chronic conditions to identify recapture risk

d. Coordinating with clinical, coding, and vendor partners to ensure gaps are prioritized appropriately

e. Translate RAF and coding data into provider education, provider facing gap reports and performance snapshot

8. Develop provider reporting and reporting that supports plan leadership efforts to drive improvement.

9. Support CMS audit readine

KNOWLEDGE, SKILLS, ABILITIES:
• Bachelor's Degree and Medicare Advantage Plan experience;
• Strong technological skills to work from multiple platforms including Microsoft Office Suite.
• Analytical capability
• Dashboard Development and ability to work with software electronic health record vendor
• Provider engagement
• Leadership & communication
• Assertive self-starter who is able to influence others;
• Strong written and verbal communication skills with abilities to deliver presentations in an impactful manner;
• Proven ability to work independently and productively as well as with a team.
• Knowledge of CMS MOC requirements for Medicare Advantage Plan
• Demonstrate compliance with CMS regulations regarding Medicare Advantage Plans and PruittHealth Code of Conduct.
• Exceptional organizational skills; strong written and verbal communication and clear-thinking skills with the ability to synthesize complex issues into simple messages;
• Have suitable home workspace allowing for productive office environment.
• Understands the HEDIS and CMS Star Ratings for Medicare Advantage Plan
• Complete annual Medicare Fraud,Waste and Abuse Training and Model of Care Training
• Performs other duties as assigned

Qualifications:

MINIMUM EDUCATION REQUIRED:

Bachelors degree required; Masters degree in Healthcare Administration, Public Health, Business Administration, Nursing, Health Informatics, or related field preferred.

MINIMUM EXPERIENCE REQUIRED:

5+ years Medicare Advantage quality, analytics, or risk adjustment experience with leadership

3+ years leadership role experience

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:

Prefer Coder/HCC Certification

ADDITIONAL QUALIFICATIONS: (Preferred qualifications)

Experience with Medicare Advantage Special Needs Plan, CMS Model of Care, HEDIS, Star Ratings, and HCC/Risk adjustment preferred

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