Title: Manager, Clinical Quality
Job Type: Full-time
Location: Hybrid - 4 days per week in Brighton, MA office; 1 day remote
FLSA Status: Exempt
Position OverviewThe Manager, Clinical Quality leads USFHP's clinical quality and accreditation programs: quality measurement, accreditation readiness and maintenance, and performance improvement. This role builds and runs the plan's quality infrastructure, coordinating HEDIS and CAHPS reporting, applying structured quality improvement methods, and driving measurable improvement in clinical quality, member experience, and health equity in partnership with clinical and operational teams.
Key Responsibilities Quality Program Management- Manage the clinical quality program, including the annual quality work plan, QI program description, measure set, and evaluation.
- Lead HEDIS data collection, medical record abstraction oversight (including interrater reliability monitoring for record review staff), hybrid/administrative measure reporting, and CAHPS survey coordination; track measure performance and identify gaps.
- Design and lead performance improvement projects using structured methods (e.g., PDSA cycles, root cause analysis, run/control charts) and manage corrective action plans.
- Lead investigations into clinical quality issues (Potential Quality Issues/PQIs), partnering with clinical nursing leadership on findings and outcomes.
Accreditation & Compliance- Lead readiness and ongoing maintenance activities for applicable health plan accreditation and regulatory standards (e.g., quality improvement, utilization management, credentialing, members' rights, network management), including standards interpretation, documentation, file review, and survey preparation.
- Support data validation activities tied to HEDIS and CAHPS reporting, and health equity requirements.
- Ensure quality processes meet TRICARE/USFHP contractual and regulatory requirements; maintain audit ready evidence and coordinate submissions.
- Monitor the accreditation landscape and advise leadership on emerging requirements or opportunities relevant to the plan's quality strategy.
Data & Reporting - Analyze quality, CAHPS, utilization, and outcome data to prioritize opportunities and inform strategy; report to leadership and committees.
- Partner with clinical, utilization, care management, network, pharmacy, and population health teams to close care gaps and improve measures.
- Staff or support the Quality Improvement Committee and related workgroups.
Collaboration & Program Leadership - Partner with clinical, utilization, care management, network contracting, and population health teams to promote culturally competent, equity driven care delivery.
- Manage staff and/or vendors: setting priorities, providing feedback, evaluating performance, and overseeing vendor deliverables (e.g., HEDIS/CAHPS vendors).
- Present clinical quality improvement results and performance measures to senior leadership and program stakeholders.
- Formulate and maintain policies, procedures, and goals in compliance with internal and external guidelines.
Qualifications Education & Experience - 5 or more years of healthcare quality or accreditation experience in managed care.
- HEDIS experience strongly preferred.
Skills & Competencies - Expertise in quality measurement, accreditation, and performance improvement methodology.
- Strong analytical, project management, and communication skills; comfortable learning new tools/systems as needed. Deep familiarity with a specific platform (e.g., Power BI, SQL) is preferred.
- Sound judgment navigating ambiguity and regulatory complexity; demonstrated ability to build structured processes where none exists.
- Familiarity with TRICARE/USFHP preferred.
Other Requirements - Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.
Physical Nature of the Job Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move throughout the campus.
Salary Description
$105,000-120,000
