What are the responsibilities and job description for the Senior Director, Risk Adjustment and Medicare STARs position at Blue Shield of CA?
Your Role
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 critical to the growth and financially viable and competitive Medicare products. This leader will develop the programs and take accountability by partnering with C-suite executive 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). 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 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/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
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
