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Provide strategic leadership for Medicare Advantage quality performance, risk adjustment, and reimbursement optimization. Monitor and analyze quality metrics, HEDIS, and Star Ratings to develop actionable provider-level strategies and ensure CMS audit readiness.
Requires a Bachelor's degree and at least 5 years of experience in Medicare Advantage quality, analytics, or risk adjustment, including 3+ years in a leadership role. Proficiency in CMS regulations, HEDIS, and Star Ratings is essential, with a Master's degree or Coder/HCC certification preferred.
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, SNP 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. Including SNP (Special Needs Plan) and Clinical Metrics.
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 sources
b. Ongoing tracking of performance against Star cut points and internal targets
c. Identification of measure level drivers for underperformance or improvement
d. Support for annual HEDIS submissions and mid-year improvement efforts
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 patterns
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 insights
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 snapshots
8. Develop provider reporting and reporting that supports plan leadership efforts to drive improvement.
9. Support CMS audit readiness
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 vendors
• 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 Plans
• Complete annual Medicare Fraud,Waste and Abuse Training and Model of Care Training
• Performs other duties as assigned
MINIMUM EDUCATION REQUIRED:
Bachelor’s degree required; Master’s 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
Understanding of SNP Pllans - Special Needs Plans
Family Makes Us Stronger. Our family, your family, one family. Committed to loving, giving, and caring. United in making a difference.
We are eager to connect with you! Apply Now to get started at PruittHealth!
As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.
For Florida Job Postings Only:
For more information regarding Florida’s Care Provider Background Screening Clearinghouse Education and Awareness, please visit https://info.flclearinghouse.com
Family Makes Us Stronger
At PruittHealth, Family Makes Us Stronger, and it is at the center of everything we do. We don’t just hire employees. We welcome partners into our family. Since its inception in 1969, PruittHealth has been a family-owned, innovative organization committed to providing exceptional care across a wide spectrum of services including: skilled nursing, assisted & independent living, home health, end-of-life hospice, rehabilitation, pharmacy/infusion services, and more. Today, the organization spans across the Southeast, touches 170 communities, cares for 24,000 patients daily, and is driven by 13,000 passionate partners. For more information please visit: www.PruittHealth.com Notice of Nondiscrimination: http://bit.ly/2eHoI5B
Offices: 1626 Jeurgens Ct, Norcross, GA 30093, US
Based on 1092 listings with disclosed salaries, most data & analytics jobs in Atlanta, GA pay between $70k–$200k per year. Individual offers vary with seniority, company size, and specialization.
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