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Stars - HEDIS Consultant

Clover Health

Remote / United States of America
  • Job Type: Full-Time
  • Function: Professional Svcs
  • Industry: Digital Health
  • Post Date: 11/22/2022
  • Website:
  • Company Address: P.O. Box 471, Jersey City, NJ 07303

About Clover Health

Clover Health is a data driven health insurance startup driving to improve the overall state of healthcare in America. We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road.

Job Description

Clover is reinventing health insurance by working to keep people healthier.

The Stars team at Clover collaborates with teams across operations, clinical, pharmacy, data science and technology to ensure the Stars strategy is implemented, executed, and will lead to improved performance across all measures. Stars operations are a critical barometer of the company's health, indicating how well we're helping our members achieve better health outcomes and how well we're functioning as a business. Medicare Star ratings also have a significant impact on the company's revenue and ability to offer better insurance benefits and higher touch care. 

We’re looking to hire a HEDIS Consultant to drive the development and execution of key Stars programs in the HEDIS domain. This key role will regularly collaborate with internal partners such as Clinical Operations, Data Science, Product, Provider Relations and Health IT to drive improvement in HEDIS performance by developing and implementing strategic projects and programs from cradle to grave. This role will also work with external partners associated with CMS required activities such as HEDIS submission, as well as partners that provide clinical care or care coordination services to drive improvement in Stars performance and meeting organization goals. This role has a particular focus on developing and driving process improvement operations, organizational change management, program management and other processes relative to the business needs.

As a HEDIS Consultant you are expected to have deep subject matter expertise on all things Stars with a particular focus on the HEDIS domain and clinical program operations/design. You will act as a key decision maker across a range of functional teams within Clover and be responsible for serving as a data SME with a laser focus on using data to identify opportunities and drive improvement across Clover’s quality outcomes. You will excel in leading and managing cross functional teams in development, planning and execution of programs that drive measurable improvements in top organizational goals and objectives.

As a HEDIS Consultant, you will:

  • Plan, develop, implement and oversee all HEDIS Stars business functions and be a key driver of overall HEDIS Strategy — leading programs that meet critical needs. You will be able to work both autonomously, owning whole projects, while also gathering appropriate insight when needed.
  • Design, develop and implement HEDIS Improvement Measure projects cradle to grave.
  • Drive and develop HEDIS analytics and tooling development including dashboarding, etc.
  • Serve as the go-to expert for any HEDIS or HEDIS clinical data related question; responsible for company wide HEDIS information and advocacy.
  • Oversee the entire annual HEDIS submission project, working to ensure that MRR is successful, rates are maximized for each submission year and off season HEDIS activities, such as year-round HEDIS abstraction, are executed.
  • Be forward thinking and collaborative about measure specific improvements.
  • Define critical KPIs and build core operating dashboards to manage performance related to HEDIS measures and initiatives.
  • Understand year over year regulation changes to the Stars program and how it will affect Clover programs and product development.
  • Present relevant strategies and results with analytical evidence to the executive leadership team.
  • Work with the Product team to scope and test user-facing features to drive HEDIS Outcomes.
  • Creates business requirement documents, test plans, requirements traceability matrix, user training materials, policy/procedure, and other related documentation.

You will love this job if:

  • You love providing guidance and leadership to multidisciplinary project teams to deliver high quality, improvement-oriented analysis.
  • You are tech and data savvy. You are used to thinking about how technology can enable better experiences and how you can use data to make better decisions.
  • You know how to drive results.
  • You value high trust, high ethics relationships and build/support these qualities in your working partners.
  • You have and value in others strong, collaborative problem-solving skills.
  • You are a seasoned critical thinker.

You should get in touch if:

  • You have deep experience (at least 5+ years) of MAPD Star Ratings focusing on HEDIS strategy experience working on related programs.
  • You have strong operational expertise in NCQA HEDIS; including technical specifications, HEDIS audit lifecycle, and completion of key audit deliverables such as MRRV and HEDIS roadmap.
  • You have active and unrestricted state licensure of RN, PA, NP degree (or similar degree/licensure with the ability to provide clinical oversight of RNs) from an accredited program (strong plus).
  • You have 5+ years of experience directly supervising and managing a high performing team (exempt and non-exempt).  
  • You have the ability to write routine reports and correspondence while applying common sense to carry out instructions furnished in written, oral, or diagram form.
  • You have strong verbal and written skills with the ability to convey complicated information in a digestible form to all levels of the organization; you are as comfortable speaking with your peers as you are with an executive.
  • You have advanced knowledge of Microsoft and Google Suites, and the ability to create and comprehend reports and spreadsheets in Excel.
  • You have working knowledge of SQL (preferred).

#LI-Remote #LI-JE1

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

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