Program Manager, Risk Adjustment – Stars

This is a fully remote position, open to applicants in California, +1 more state.

📋 Description

• Take ownership of the yearly risk adjustment and Stars enhancement program cycle, encompassing both prospective and retrospective initiatives, visit-based campaigns, and gap closure workflows.

• Develop and oversee program timelines and throughput; provide progress reports to Alpine leadership and health plan partners.

• Lead cross-functional workgroups that include coding/HCC, clinical quality, IT, and analytics.

• Manage program documentation and requirements, converting technical specifications into actionable operational plans.

• Act as a liaison between coding/data teams and operational stakeholders regarding HCC capture, chart review, and gap identification workflows.

• Oversee vendor relationships and coordinate technical file exchange and integration requirements.

• Monitor trends in RAF scores and performance results, translating insights into operational action plans.

• Ensure accuracy in risk adjustment data submissions and EDS reconciliations.

• Track transitions in HCC model versions and communicate their operational and financial implications.

• Coordinate Star Ratings strategies across HEDIS, CAHPS, HOS, and medication adherence metrics.

• Collaborate with analytics teams on performance tracking, cut-point modeling, KPIs, and dashboards.

• Serve as a primary contact for health plan Stars/quality teams.

• Identify and escalate data integrity concerns across claims, EHR, and supplemental data feeds.

• Present performance outcomes and program recommendations to executive leadership and payer partners.

• Ensure compliance with CMS regulations, ICD-10-CM coding standards, and company policies.

• Support RADV audit readiness and health plan data validation inquiries.

⛳️ Requirements

• A bachelor's degree in health informatics, data analytics, healthcare administration, business, or a related field is required.

• 5 to 7 years of experience in Medicare Advantage risk adjustment and/or Star Ratings/quality improvement.

• Familiarity with CMS HCC risk adjustment models, RAF score methodology, EDS submission processes, and Star Ratings measure specifications.

• Proven ability to collaborate with technical teams and operational/business stakeholders, effectively translating between them.

• Demonstrated program/project management experience in managing cross-functional technical and operational initiatives.

• Proficiency in Excel is required.

• Strong written and verbal communication skills.

• Excellent relationship management and cross-functional collaboration abilities.

• Capacity to interpret data and technical findings and convert them into operational plans.

• Adaptability to changing CMS methodologies and health plan requirements.

• Willingness to travel for meetings.

• Ability to manage multiple concurrent demands in a high-stress environment, with skills in organization, coordination, prioritization, and deadline management.

• A HIPAA-compliant home office is required for remote or telecommuting positions.

• Preferred qualifications include CRC credential, experience in value-based care/ACO/delegated risk, familiarity with multiple health plan Stars/quality programs, PMP or similar certification, and knowledge of SQL/Tableau/Power BI.

🏝️ Benefits

• Eligibility for an annual bonus based on individual and/or company performance.

• Medical insurance.

• Dental insurance.

• Vision insurance.

• 401(k) plan.

• Paid time off (PTO).

• Employee Assistance Program (EAP).

• A HIPAA-compliant home office is required for remote or telecommuting positions.