Senior Director, Risk Adjustment and Medicare STARs

Your Role

All potential candidates should read through the following details of this job with care before making an application.

The Senior Director, Risk Adjustment and Medicare STARs role will lead the Medicare Risk Adjustment and Stars programs, two functions that drive appropriate revenue and thus are critical to the growth and financial viability of competitive Medicare products.

This leader will develop the programs and take accountability by partnering with C-suite executives and cross-functional senior leaders across multiple health plans (national) for better encounter data and member quality outcomes (including member / provider education and engagement initiatives, vendor management).

The Senior Director is accountable for national health plans strategy and achieving performance goals for the Part C and D measures of the Stars program for all Medicare products and related programs that influence Stars ratings.

This role will design and implement Medicare Stars strategies across multiple Blue organizations across the country to achieve demonstrable improvements in the Plan's CMS Star Ratings measures leading to 4+ Stars on a continuous basis.

This strategic leader ensures accurate coding accuracy and submission of health conditions for beneficiaries in Medicare Advantage plans.

The program will have oversight of encounter data processes as well as retrospective and prospective initiatives. The Senior Director is accountable for preparation for and management of the Center for Medicare and Medicaid Services (CMS) auditing processes and management of applicable state and federal guidance.

The Risk Adjustment Program is critical as it ensures that the health conditions of the beneficiaries in a Medicare Advantage plan are accurately captured.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially.

We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will :

Strategically manage health plan relationships with C-suite / SVP executives. Design and lead a national strategy that is applied to individual state plans.

Focus extends beyond mere transactions and encompasses performance optimization and process refinement resulting in a best-in-class Medicare Program.

Collaborates and maintains relationships with C-suite executives across multiple health plans in service of managing client.

• Own developing strategic prospective and retrospective risk adjustment review program and integration that follow all government regulations to drive accurate coding in support of accurate risk capture.
• Accountable for success of end-to-end Stars strategy and performance. Partnering with Health Plan executive leadership to continually refine and drive strategic improvements, maintains relationships with external stakeholders across multiple health plans and vendors ultimately ensuring a motivated and customer-oriented organization.

Drives CAHPS (CX) and HEDIS (Clinical / Pharmacy) quality performance improvement programs.

Interact with prospective Health Plans (C-suite and SVPs) as our Medicare leadership SME and instruct process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes of Strategic Services Group offerings.

Supports provider partnerships, data / information sharing, reporting, tools, and resources to drive maximized revenue, reduce administrative cost and support membership growth.

Accountable for end-to-end Risk Adjustment for Medicare Advantage. Directs and oversees Risk Adjustment strategy, internal and external audit preparation, and risk mitigation;

data analysis to support risk revenue accruals; Center for Medicare and Medicaid Services (CMS) encounter data submissions for Medicare plans to ensure complete and accurate risk capture.

This requires seamless integration with multiple service functions (e.g. actuary, clinical quality, and audit, vendor management, project management, capability development, and provider education).

Establishes goals and policies with the VPs of operational and analytics teams, continually challenges leaders and their teams to evaluate processes and capabilities to further improve efficiencies and evaluate performance of the Risk Adjustment program.

Collaborate with network leadership; and supports vendor / provider partnerships - including data / information sharing, reporting, tools, and resources - to drive revenue enhancement programs.

Drives strategic improvements, maintains relationships with internal and external stakeholders to ensure a cohesive program that is member and provider focused.

• Manages universal relationship strategy for vendor relationships which includes performance management and process improvements to increase quality and efficiencies for Risk Adjustment strategies and Stars initiatives.
• Oversees program governance and management, including evaluating existing operational metrics, and developing new metrics as necessary, to better assess the performance of the organization in achieving corporate objectives and mitigating compliance risks.
• Leads, coaches, and instructs process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes aimed at optimizing programs through Member and Provider Engagement initiatives.
• Collaborates and coordinates with internal and external stakeholders to work through barriers, manages multiple competing priorities and resources, and influences activity both inside and outside of direct accountability.
• Plan, develop, and implement effective improvement strategies to achieve high performance for Medicare Part C and D Stars.

Effectively lead and partner with cross-functional business units in planning and executing Stars improvement strategies and programs.

Key functional areas supported include developing and executing new Stars performance improvement initiatives, managing, and standardizing existing improvement projects, evaluating and optimizing programs to deliver impact, and reporting and compliance.

• Lead and implement performance analytics with an aim to identify areas of opportunity, key drivers, and assessment of the impact on improvement and measuring performance.
• Develop strategic direction, training and goals for departments and cross-functional teams.
• Collaborate with cross-functional teams to assure regular tracking of program KPIs to inform timely follow-up, escalation of gaps and barriers, and advancement of innovative workflows to support and promote quality improvement initiatives.

Your Knowledge and Experience

• Bachelors degree in Health Administration, Business, Finance or related field; Master's degree preferred
• Minimum ten (10) years' experience in a combination of quality, provider engagement and / or risk adjustment, with at least 6 years in a senior leadership role
• Minimum of ten (10) or more years of current progressive, operational experience in a health plan or managed care setting with a focus on excellent process and execution.

Five (5) years of strong senior level leadership / management experience is required

• Demonstrated knowledge of Center for Medicare and Medicaid Services (CMS) practices, policies, and regulations
• Experience with strategy development, execution, planning, and management of high priority / high visibility projects related to corporate enterprise efforts
• Proven track record of developing and implementing successful Risk Adjustment and Stars processes and regulations
• In-depth knowledge of Medicare Advantage, Risk Adjustment processes and regulations
• Excellent leadership and team management abilities with a history of developing high performing teams
• Experience with managed care software and analytics tools
• Process improvement knowledge and experience
• Comprehensive knowledge of payer environment and healthcare systems
• Strong financial management, organizational, negotiation, analytic, problem solving and management skills, with the ability to interpret complex data
• Effective communication and interpersonal skills, with the ability to influence stakeholders at all levels
• Demonstrated track record of driving large-scale business change, particularly in a matrix environment

Pay Range :

The pay range for this role is : $206,470.00 to $309,650.00 for California.

Note :

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade.

Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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