Provider Quality Leader V

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Provider Quality Lead is a strategic and operational leader responsible for driving provider performance across all lines of business-Medicare, Medicaid, Commercial, and Individual & Family Business (IFB)-with a primary focus on Medicare and close partnership with Medicaid. This role is the connective tissues between to Network, Provider Engagement, and Quality & Stars to formulate and executing strategies designed to improve Quality across all line of business. This role leads provider engagement, quality performance management, and the development of incentive programs to achieve Medica's quality goals, including 4+ Star performance. The role will also build and lead a dedicated Provider Quality team, and partner across departments to ensure alignment on attribution methodologies, financial impact of quality incentives, and CMS contract specific performance measures. Performs other duties as assigned.

Key Accountabilities

• Provider Relationship & Performance Management
  
  
  
  • Lead direct engagement with provider organizations across all lines of business for quality initiatives and programs
  • Partner with all LOBs on Quality outcomes and measures with an emphasis on Value Based Care (VBC) and Medicaid teams to align on quality goals (Withhold Measures for Medicaid and Stars Measures for Medicare) and execution strategies
  • Ensure provider accountability through transparent data sharing and performance reviews
  
  
  
  

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  Provider Incentive Program Design & Management

  
  
  
  
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    Design and manage annual provider incentive programs tailored to provider types and lines of business

    
    
  • Oversee attribution methodologies, performance tracking, and quarterly (or monthly) reporting
  • Ensure financial accuracy and reasonableness of quality incentive payments in alignment with contract terms
  
  
  
  

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  Contractual Quality Program Integration

  
  
  
  
  • Collaborate with Network and Contracting teams to design and negotiate quality components within VBC and Non-VBC contracts
  • Validate performance targets and ensure alignment with data assets and financial impact
  • Review, respond, provide direct input to RFP process e.g., Medicaid State RFPs
  
  
  
  

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  Attribution Methodology Partnership

  
  
  
  
  • Partner with internal teams to understand, validate, and refine attribution methodologies
  • Ensure provider attribution is accurate, complete, and aligned with performance measurement
  
  
  
  

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  Supplemental Data & PSV Management

  
  
  
  
  • Collaborate with HEDIS Data and Performance teams to initiate and manage supplemental data feeds
  • Oversee Primary Source Verification (PSV) from the provider side, including sample execution, chart retrieval, provider communication, and data submission processes
  • Ensure data integrity, completeness, and compliance with CMS and internal standards
  
  
  
  

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  Performance Monitoring & Gap Closure

  
  
  
  
  • Lead monthly analysis of provider performance data, identifying trends and opportunities for improvement
  • Drive initiatives to close care gaps and achieve 4+ Star performance across Medicare contracts
  
  
  
  

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  Strategic Planning & Execution

  
  
  
  
  • Develop and communicate the annual Provider Quality strategy, including vision, goals, and KPIs
  • Collaborate with Stars and Quality teams to align and execute strategies across lines of business
  • Partner with Stars leadership to develop CMS contract specific measures and improvement plans
  
  
  
  

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  Team Development & Leadership

  
  
  
  
  • Build and lead the Provider Quality team, including recruitment, onboarding, and development
  • Foster a culture of collaboration, accountability, and continuous improvement
  
  
  
  

Required Qualifications

• Bachelor's degree in Healthcare Administration, Public Health, Business or equivalent experience in related field; Master's degree preferred
• 10 years of related work experience beyond degree

Skills and Abilities

• 5+ years of experience in healthcare quality, provider relations, or value-based care
• RN, LPN preferred
• Experience with CMS Stars, HEDIS, Medicaid, Individual and Commercial quality programs
• Strong understanding of healthcare data, attribution methodologies, financial modeling of quality incentives, and P & L impacts on business segments
• Proven ability to lead cross functional initiatives and manage complex projects
• Ability to analyze and summarize, and trend data to make it absorbable by our provider partners
• Excellent communication, negotiation, and relationship building skills
• Experience managing teams or demonstrated leadership potential preferred

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, Omaha, NE, or St. Louis, MO.

The full salary grade for this position is $98,400 - $168,600. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $98,400 - $147,525. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic