STARS Quality Specialist

About the role

The Quality STARS Specialist supports a clinical health plan's CMS Star Ratings performance by monitoring quality measures and translating data into actionable insights that improve care delivery, member experience, and outcomes.

Responsibilities

• Data Monitoring and Reporting
• Track performance on CMS Star Ratings measures across HEDIS, CAHPS, HOS, pharmacy, and operational metrics.
• Prepare routine and ad hoc reports for leadership, quality teams, and operational partners.
• Identify performance gaps using data analysis and recommend targeted interventions.
• Maintain dashboards, scorecards, and measure level documentation.
• Quality Improvement Support
• Assist in developing and executing quality improvement initiatives to raise Star Ratings.
• Serve as a subject matter expert in Star Ratings methodology and analytics, supporting regulatory compliance, audit readiness, program coordination, and process improvement to strengthen quality performance and operational effectiveness.
• Cross-Functional Collaboration
• Work closely with departments such as Quality, Clinical Operations, Member Experience, Provider Relations, Pharmacy, and IT.
• Support provider engagement efforts, including distributing measure education, performance summaries, and best practices.
• Participate in internal workgroups focused on improving specific STARS measures.
• Regulatory & Compliance Support
• Stay current on CMS Star Ratings methodology, technical specifications, and regulatory updates.
• Ensure internal processes align with CMS requirements and audit expectations.
• Absorb and prepare documentation for audits, mock audits, and compliance reviews.
• Program Coordination & Administration
• Manage timelines, deliverables, and project tracking for STARS initiatives.
• Support vendor coordination, including data exchange, reporting, and performance monitoring.
• Maintain organized records of program activities, interventions, and outcomes.
• Aid in annual planning for STARS strategy and operational execution.
• Help design and execute outreach campaigns to improve member experience and close gaps in care.
• Support provider education on measure requirements, coding accuracy, and documentation standards.
• Coordinate distribution of materials, toolkits, and communications.
• Process Improvement
• Identify workflow inefficiencies and recommend enhancements to improve measure performance.
• Support implementation of new tools, processes, or technologies that streamline STARS operations.
• Document standard operating procedures (SOPs) and maintain process guides.

Qualifications

• Bachelor's Degree required (experience can be substituted in lieu of degree); Master's Degree preferred.
• At least 2-3 years of experience in a CMS STARs role, specializing in STARs program execution required.
• At least 2-3 years experience managing STARs data, data validation, and outcomes required.
• At least 5-7 years in health plan quality in a managed care organization highly preferred.
• Experience in healthcare quality, STARs initiatives, population health, or related program coordination highly preferred.
• Familiarity with QI methodologies and regulatory standards highly preferred.
• Experience working with diverse communities or in community health, managed care, or hospital quality departments preferred.
• Experience with SDOH screening tools, community partnerships, or health literacy initiatives preferred.
• Certification in healthcare quality or equity (e.g., CPHQ, CPHE, Lean Six Sigma) preferred.

Skills and Abilities

• In-depth knowledge of healthcare regulations, accreditation standards, STARs program and quality improvement methodologies.
• Strong understanding of document management systems (DMS), such as SharePoint, OpenText, or Documentum, to manage digital files, track revisions, and maintain version control.
• Familiarity with cloud storage systems and collaboration tools like Google Drive, Dropbox, and Microsoft OneDrive.
• Experience with electronic records management (ERM) and data retention policies.
• Demonstrates awareness of importance of security, scalability, reliability and feasibility in solutions.
• Seeks out information to better understand impacts of design and implementation of systems.
• Evaluates service areas to identify opportunities for automation.
• Knowledge of compliance standards, including industry-specific regulations (e.g., healthcare HIPAA regulations, financial regulations, state and federal rules).
• Strong organizational skills to ensure policies and documents are properly filed, categorized, and easy to access.
• Ability to spot discrepancies or issues in documents and ensure compliance with required guidelines.
• Understanding of legal and regulatory requirements for document retention and management, including data privacy and security laws.
• Knowledge of audit procedures and the ability to prepare documentation for audits.
• Excellent written and verbal communication skills for drafting policies and procedures, as well as providing guidance to employees about document handling and compliance.
• Ability to train staff on document management practices and policy changes.
• Experience using document management software and workflow tools to streamline document processes and improve efficiency.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and other productivity tools is often required.
• Familiarity with document control software for versioning, workflow management, and access permissions.
• Ability to manage multiple tasks or projects simultaneously, adhering to deadlines and ensuring that policies and documents are up to date.
• Experience with project management software, such as Trello or Microsoft Project, is beneficial.
• Ability to identify issues with document flow, retention, or compliance and propose solutions to resolve them.
• Strong critical thinking skills for analyzing policies and procedures to ensure they align with organizational goals and legal requirements.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.