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Clever Care Health Plan · 3 days ago

Vice President, Risk Adjustment and Quality

Huntington Beach, CA

Full-time

Hybrid

Mid, Senior Level

$200K/yr - $250K/yr

7+ years exp

Clever Care Health Plan is one of Southern California’s fastest-growing Medicare Advantage plans. The Vice President of Risk Adjustment and Quality is accountable for developing continuous improvement strategies and directing implementation to achieve operational excellence in CMS Star and Medicare Risk Adjustment programs.

Health Care

H1B Sponsor Likely

Responsibilities

Develop strategy and tactical processes, in collaboration with the Clever Care’s internal teams and Physicians/IPA/MSO partners, to operationalize and execute MRA and HEDIS/Star procedures including, but not limited to, prospective programs, concurrent/retrospective review, submissions, submission reconciliation, quality control and compliance

Oversee the formulation, direction, implementation, administration, supervision, and planning of enterprise-wide performance measurement-based strategies relative to MRA and Quality measures

Drive the definition, measurement, and implementation of process improvement activities and projects in support of corporate goals

Direct the review and analysis of data to evaluate clinical and administrative service improvement activities and programs

Evolve MRA and Star program strategy to achieve improved and cost-effective results, while eliminating sources of uncertainty

Design, implement, and monitor incentive programs for both Quality and Risk Adjustment initiatives, ensuring alignment with organizational goals and CMS compliance

Develop performance-based incentive structures for providers, IPAs, and internal teams to improve HEDIS, CAHPS, HOS, and Risk Adjustment outcomes

Analyze incentive program effectiveness through data-driven metrics and adjust strategies to maximize impact on Star Ratings and MRA performance

Partner with IT and Data Analytics teams to optimize risk adjustment models, predictive analytics, and dashboard reporting

Oversee all critical program vendors, including setting the strategy on outsourcing vs. insourcing, assessing new partner opportunities, initiating new relationships, and managing performance of existing partners

Responsible for ensuring that the definition and formulation of data-driven strategies, as well as the management and operational activities across Quality Management, Medical Management, Pharmacy Services, and other areas of the organization are designed to increase Clever Care Health Plan quality ratings (Medicare Star Ratings, Quality Incentive Awards, and Quality Rankings) occurs in an efficient and effective manner, and in compliance with NCQA, state and federal regulations and requirements

Spearhead the AWV and in-home vendor programs’ execution with appropriate tactics and reporting requirements in place

Oversee chart retrieval programs completed by vendor and internal teams

Oversee coding and documentation, provider education, sweeps & RADV audit programs and processes

Manage HCC improvement and encounter error research/resolution projects

Improve core process efficiency, effectiveness, and responsiveness; measure and improve business critical operational KPIs/metrics, especially in the areas of member satisfaction/loyalty/retention, and provider access and availability

Direct the application of the Customer and Business data to scope the level of improvement required to impact MRA programs, Star ratings, customer experience and loyalty and bottom-line results

Work with appropriate entities (internal or external) to reduce encounter/claims rejects from CMS, any vendor projects, and clearing house(s)

Support the implementation of the Member Rewards Program implementation and ongoing monitoring across the enterprise

Oversee the department’s member engagement efforts by developing year-round campaign strategy and parameters

Oversee the Quality and STARS teams to ensure optimal results are obtained for the CMS Stars program including HEDIS measures, CAHPS and HOS scores

Partner with Operations teams to improve the member experience as measure in the Stars program

Oversee team that investigates and resolves/tracks quality of care issues that come from members/providers/UM process

Other duties as assigned

Qualification

Medicare Risk AdjustmentHEDIS/Star program managementProgram performance measurementData analyticsCertified Professional in Healthcare QualityCertified Risk Adjustment CoderProject Management ProfessionalLeadership skillsProblem solving skillsOrganizational skillsCommunication skillsTime management skills

Required

Bachelor's degree in Business, Healthcare, or related field required

Minimum seven (7) years' experience in healthcare/managed care industry with experience in Medicare Risk Adjustment (MRA), HEDIS/Star/CAHPS and HOS program management and leadership

Experience in program performance measurement, analytics, reporting and forecasting for MRA & Quality programs/measures

Ability to effectively communicate in multiple formats to varied audiences (leadership, clinicians, office staff, etc.) on a variety of complex topics

Knowledge, understanding, and accurate interpretation of product line related specifications, methodologies, and processes, and of MRA/HEDIS/Star processes

Excellent leadership skills and the ability to influence line management decisions with data driven facts

Strong management, problem solving, priority setting skills

Strong independent decision-making skills

Strong organizational skills including time and project management skills

Computer proficiency in MS Office applications (word processing, spreadsheet/database, presentation)

Possess strong results-oriented process improvement capabilities

Strong problem solving and analytical skills to be applied to a wide array of business problems and challenges

Detail oriented with exceptional written and verbal communication skills

Ability to maintain composure and effectiveness in a rapidly changing environment with minimum direction

Must be a self-starter and independent thinker

Preferred

Master's degree preferred

Certified Professional in Healthcare Quality (CPHQ)

Certified Risk Adjustment Coder (CRC)

Project Management Professional (PMP)

Company

Clever Care Health Plan

Clever Care Health Plan is a healthcare company that provides health insurance for medicare services.

Founded in 2018

Huntington Beach, California, USA

201-500 employees

https://clevercarehealthplan.com

H1B Sponsorship

Clever Care Health Plan has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (2)

2023 (4)

2022 (3)