RN-Quality Clinical Management Advisor

The Cigna Group • Bloomfield, CT, USA • 1w ago

Job Summary

Leads clinical quality measurement and improvement activities, ensuring successful execution of Healthcare Effectiveness Data and Information Set (HEDIS®) while advancing the transition to digital quality measurement (dQM). Accountable for market performance, regulatory compliance, vendor management, and the modernization of data acquisition, measurement, and reporting capabilities.

Scope & Impact

Primary market lead for end-to-end HEDIS execution and performance outcomes
Drives measurable improvement in quality metrics and Stars/HEDIS performance
Leads adoption of digital quality measurement capabilities, including EHR-enabled data capture and interoperability
Influences cross-functional teams (clinical, IT, provider, vendor, customer facing, and enterprise stakeholders)
Manages vendors, budget, and operational efficiency for quality programs

Key Responsibilities

1. HEDIS/QRS Market Leadership

Direct annual HEDIS production, submission, and audit readiness
Own market-level performance strategy, identifying and closing care gaps
Lead state-specific submissions and regulatory requirements
Serve as SME on HEDIS specifications, abstraction, clinical data acquisition, and reporting

2. Digital Quality Measurement (dQM) Transformation

Lead transition from hybrid/manual to digital quality measurement
Partner with IT and vendors to enhance clinical data acquisition (EHR, HIE, FHIR-enabled sources)
Modernize workflows, clinical data acquisition, and reporting

3. Data & Analytics Enablement

Translate performance data into actionable insights for clinical and operational teams
Identify automation and process optimization opportunities to reduce manual effort and cost

4. Vendor & Project Management

Manage vendor relationships, deliverables, and performance
Oversee contractor resources and ensure accountability to timelines and outcomes
Manage budget and drive operational efficiencies
Lead cross-market and national initiatives

5. Stakeholder & Matrix Leadership

Partner with Market Medical Executives, Provider Experience, Contracting, IT, Legal, and Clinical teams
Support client-facing engagements and performance discussions
Represent organization in external quality collaborations and initiatives

Required Qualifications

Bachelor's degree; Registered Nurse (RN) required
3-5 years HEDIS measurement and reporting experience
5+ years clinical quality/performance improvement experience
Strong knowledge of NCQA, and regulatory requirements
Experience in managed care or healthcare delivery environment
Demonstrated project management, analytical, and communication skills

Preferred Qualifications

Master's degree (Nursing, Public Health, Informatics, or related field)
Experience with digital quality measurement and data modernization initiatives
Proficiency with EHR Systems and MS Excel
Knowledge of clinical data standards and interoperability (e.g., FHIR, HL7), and Tableau, PowerBI, and healthcare interoperability solutions
Vendor management experience

Core Competencies