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Description

The Director for Quality and Risk Adjustment is responsible for leading enterprise development of the Medicare Star Ratings and Enterprise Risk Adjustment strategies that ensure our risk adjusted and Star members are getting the right clinical and pharmacy care at the right time. This role is a hybrid/remote role.

This leader drives cross-divisional execution of a multi-year strategy to achieve and maintain a Star Rating of 4+ and ensure risk score accuracy and completeness in all enterprise risk adjustment activities. Development of strategy includes integrating the Star and Risk Adjustment approach to provider engagement, payment and risk sharing models, collaborative care models, data/analytics support, member engagement, health improvement and management programs and collaboration with vendor partners to achieve identified goals. Operational integration and coordination with impacted divisions within the company to ensure support and coordination with the programs and functions including medical management, claims payment, consumer experience, product development, network management, data and analytics, grievance and appeal management, and client service to drive successful integration with the Risk Adjustment strategy. The Director will work in close collaboration with executive leadership of company representing Medical Management, Finance, Network Management, Operations, and other divisions.

Primary Responsibilities

• Lead enterprise efforts to maximize the Medicare CMS Star Rating and other quality programs supporting commercial, ACA, and Medicaid lines of business.

• Ensure complete, compliant, and accurate risk scores in all risk-adjusted market segments. Develop a multi-year strategy in collaboration with organizational stakeholders including Health Care Management, Client Services, Network Operations, and other business units as needed to drive process change across the organization to improve performance.

• Lead the strategic direction of quality assurance, coding, submissions, and audit services for risk adjustment revenue optimization.

• Develop roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective. Collaborate with analytics team to measure the effectiveness of initiatives and process improvements.

• Coordinate with existing vendors, and/or identify and implement new vendors, in order to drive desired outcomes in risk-adjustment activities.

• Coordinate activities of Star improvement and risk adjustment accuracy and completeness such that maximum benefit is derived with minimized provider and member abrasion.

• Lead, coach, and instruct process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes aimed at optimizing clinical, operational, and member experience quality.

• Create and lead cross-departmental initiatives to change processes such that members experience improved satisfaction with the health plan and are less inclined to dis-enroll.

•Oversee clinical Star-related clinical operations and ensure clinical initiatives for regulatory compliance and organizational alignment.

Requirements

• 7+ years of related professional experience, with 3+ years of management experience. All relevant experience including work, education, transferable skills, and military experience will be considered.

• Strong knowledge of Medicare Star Ratings and risk adjustment programs.

• Demonstrated ability to lead cross-functional teams through a dynamic strategic planning process that maximizes opportunities to meet business objectives.

• Superior executive level communication, facilitation, and presentation skills.

• Ability to navigate ambiguity in a complex and matrixed environment.

• Must be a strategic problem solver, with a high level of intellectual curiosity and openness to change.

• Proven leadership ability exemplified by a capacity to think strategically and implement tactically to consistently deliver results, well-developed skills in diplomacy and collaboration.

• Excellent communication, interpersonal and presentation skills.

• Candidates must possess the highest ethical standards.

Robert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

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Robert Half will consider for employment qualified applicants with arrest or conviction records in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.

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