Job Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Director, HEDIS & Quality Performance, is accountable for developing and executing the enterprise strategy to drive HEDIS performance across all lines of business, with emphasis on HEDIS measures contributing to the Medicare Advantage Stars program. This leader will serve as the organization's enterprise subject matter expert and strategic architect for HEDIS performance, including HEDIS measures contributing to Medicare Advantage Stars ratings, translating CMS and NCQA requirements, performance data, market intelligence, and industry best practices into actionable strategies that improve clinical quality, member outcomes, provider performance, operational effectiveness, and HEDIS results. This role requires deep expertise across HEDIS measurement, quality improvement, data acquisition and completeness, provider performance, intervention design and audit readiness and the transition to digital quality measurement. The Director will lead through influence across a highly matrixed organization, building shared accountability for HEDIS outcomes and visibility to an enterprise plan. The Director will own and orchestrate cross-functional HEDIS plans, establish clear performance expectations, and drive follow-through across participating functions. The Director will oversee a sizeable team of direct/indirect reports, with additional matrixed oversight and influential collaboration with a multitude of related stakeholders. This leader will also build the organization’s internal HEDIS capability by developing talent, strengthening measure expertise, and creating sustainable processes that reduce reliance on individual employees, manual workarounds and fragmented institutional knowledge

Responsibilities and Qualifications

• Develop, lead and own the multi-year enterprise HEDIS strategy, including HEDIS measures that influence Medicare Advantage Star Ratings, with clear targets, priorities, owners, performance routines, and measurable business outcomes.
• Translate CMS, NCQA, Stars methodology, regulatory changes, performance data, and industry trends into actionable priorities that improve quality outcomes, provider performance, and operational effectiveness.
• Oversee the full HEDIS lifecycle, including data acquisition, supplemental data, chart retrieval, abstraction, validation, audit readiness, submission, and the transition to digital quality measurement.
• Monitor performance across measures, providers, markets, products, and populations; identify gaps, risks, and high-value opportunities; and ensure timely corrective action.
• Build and manage a portfolio of HEDIS improvement initiatives, provider performance strategies, and digital quality transformation efforts with defined ownership, milestones, expected impact, cost, timing, and effectiveness measures.
• Partner across Provider Network, Analytics, Data/IT, Government Programs, Care Management, Pharmacy, Member Experience, Compliance, vendors, auditors, and consultants to align execution and improve outcomes.
• Establish governance, decision rights, escalation paths, and shared accountability across functions responsible for HEDIS results.
• Develop forward-looking forecasts, performance reporting, early warning indicators, and executive-level insights that clearly communicate results, risks, opportunities, and recommended actions.
• Lead, develop, and retain HEDIS and quality talent while strengthening measure-level expertise, documentation, cross-training, succession planning, and sustainable operating processes.
• Foster a culture of focus, transparency, disciplined execution, constructive challenge, and shared accountability for quality performance.
• Establish measure-level forecasts, early warning indicators, and performance routines that distinguish true improvement from data timing, attribution, denominator movement, or retrospective chart retrieval.
• Provide strategic oversight of provider, vendor, auditor, and consultant partnerships that materially affect HEDIS performance, including expectations, accountability, and intervention effectiveness.

Skills:

• Proven ability to lead complex, cross-functional initiatives in a highly matrixed organization spanning clinical, provider, analytics, pharmacy, and technology functions.
• Strong analytical and financial acumen, translating quality performance into business and financial implications.
• Exceptional executive communication, presentation, and influencing skills.

Knowledge:

• Demonstrated expertise in ECDS reporting, clinical data acquisition and interoperability (including FHIR and standardized clinical terminology), and the transition from hybrid to digital quality measurement.
• Advanced knowledge of HEDIS methodology, NCQA requirements, CMS Star Ratings, supplemental data, and measure specifications.

Experience:

• Minimum 7 years of progressively responsible experience leading HEDIS strategy and improvement in a health plan, with measurable results on measures contributing to Medicare Advantage Star Ratings.
• Demonstrated SME depth in medical record retrieval, abstraction, over-read, validation, and audit readiness.
• Preferred Qualifications
• Experience at a consistently high-performing Medicare Advantage plan, including 4+ or 5-Star organizations, across HMO, PPO, and/or D-SNP products.
• Experience integrating HEDIS strategy with CAHPS, medication adherence, provider performance, and risk adjustment.
• Experience with HEDIS vendors, NCQA-certified auditors, quality technology platforms, and EHR/clinical data exchange.
• Lean, Six Sigma, or related quality improvement certification; experience presenting to C-suite or Board-level committees.

Education and Certifications:

• Master’s degree in healthcare administration, public health, nursing, health sciences, business, health informatics, or related field.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.