Medicare Quality & Risk Adjustment Program Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Accountable for the operational leadership and coordination of Medicare Advantage Quality, HEDIS, Stars, Risk Adjustment, and audit readiness initiatives.

• Act as the primary subject matter expert and operational lead for HEDIS reporting, supplemental data collection, vendor management, provider reporting, execution of risk adjustment programs, chart retrieval activities, RADV readiness, and performance improvement efforts.

• Collaborate with internal stakeholders, provider organizations, consultants, and vendors to ensure precise reporting, regulatory adherence, and the attainment of organizational quality and risk adjustment objectives.

• Organize annual HEDIS reporting activities and prepare for NCQA audits.

• Function as the main liaison with HEDIS auditors and external quality vendors.

• Keep HEDIS Roadmap documentation, audit tracking tools, and compliance requirements up to date.

• Supervise monthly HEDIS data refresh processes, validation activities, and supplemental data collection efforts.

• Manage HEDIS vendor applications and associated workflows.

• Track HEDIS and Stars performance trends and identify areas for enhancement.

• Generate and disseminate quality performance reports, gap analyses, and leadership updates.

• Assist Stars measure owners with performance monitoring, execution of strategies, and initiatives to close gaps.

• Organize quality improvement campaigns and member outreach efforts.

• Assess and implement new data sources that enhance the accuracy of HEDIS reporting and digital quality measurement capabilities.

• Act as the operational lead for Risk Adjustment program initiatives and vendor coordination.

• Oversee RA Vendor platform administration, project configuration, user access, and workflow management.

• Coordinate prospective and retrospective risk adjustment initiatives, including chase creation and project oversight.

• Supervise chart retrieval operations, medical record collection, and provider outreach efforts.

• Organize coding sweep projects, chart packaging, coding vendor activities, and project timelines.

• Monitor Clinical Intelligence outputs, suspect identification performance, and tuning opportunities.

• Support monthly roster loads, report generation, and the integration of risk adjustment data into provider reporting processes.

• Coordinate RADV readiness activities, including chase creation, medical record retrieval, documentation management, and audit response support.

• Track operational metrics such as retrieval rates, coding completion, suspect conversion, chart completion, and project turnaround times.

• Collaborate with consulting partners and coding vendors to pinpoint process improvements and optimize program effectiveness.

• Perform hands-on medical record abstraction and clinical data extraction from provider EHRs to facilitate risk adjustment data validation, coding, and RADV audits.

• Organize the production and distribution of provider gap closure reports and performance metrics.

• Ensure the integration of HEDIS, Stars, and Risk Adjustment data into provider-facing reports.

• Validate the accuracy of reports and aid in provider engagement activities.

• Partner with Business Intelligence teams to uphold data integrity and consistency in reporting.

• Serve as the primary operational contact for vendors related to quality and risk adjustment.

• Coordinate project timelines, deliverables, issue resolution, and performance assessments.

• Maintain SOPs, workflows, training materials, and process documentation.

• Assist in the implementation of new programs, technologies, and reporting enhancements.

• Ensure compliance with CMS, NCQA, and organizational standards.

⛳️ Requirements

• A minimum of 2 years of experience in health plan operations specifically related to Medicare Advantage Quality, HEDIS, Stars, or Risk Adjustment.

• At least 3 years of clinical practice experience within an acute, ambulatory, or managed care setting.

• Proven experience in supporting HEDIS reporting, performance monitoring, and quality improvement initiatives.

• Familiarity with risk adjustment workflows, chart retrieval, coding vendor coordination, or HCC documentation processes.

• Knowledge of CMS Medicare Advantage regulations, NCQA HEDIS audit processes, and RADV requirements is essential.

• Preferred experience of 3 to 5 years in Medicare Advantage quality performance, Stars improvement, or risk adjustment program execution.

• Experience in supporting or leading cross-functional initiatives involving Quality, Member Experience, Risk Adjustment, Compliance, and Provider Engagement.

• Background in project management, workflow optimization, or vendor oversight within a health plan setting.

• Experience working with population health, value-based care programs, or provider performance reporting.

• An active, unrestricted Registered Nurse License is required.

• A Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related field is necessary.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching.

• Generous paid time off and holidays.

• Professional development opportunities and continuing education support.

• Flexible work arrangements to promote work-life balance.