• Spearhead the development, execution, and management of Clinical Programs, driving the achievement of departmental Key Performance Indicators (KPIs) encompassing financial, clinical, and operational targets.
• Cultivate and manage strategic relationships between population health and external provider engagement teams, ensuring seamless data aggregation and dissemination to enhance Provider Partnerships and performance.
• Contribute to risk adjustment and quality functions across various domains, including Prior Authorization, Concurrent Review, Care Management, Appeals, Complaints and Grievances, Quality Improvement, Member Satisfaction, Community Engagement, Government Contracts, Compliance, and Provider Engagement in alignment with the organization's overarching strategic objectives.
• Foster seamless collaboration and alignment between Population Health and other vital departments within the division, such as Utilization Management, Quality, Coding Education, and Specialty Pharmacy.
• Ensure compliance with State Medicaid and CMS regulations, focusing on Risk Adjustment and Quality guidelines.
• Provide adept leadership over project work within the Department and Division as necessitated by organizational goals and objectives.

• Profound understanding of risk adjustment and quality activities, along with clinical informatics within provider or health plan environments.
• Exceptional leadership acumen demonstrated through effective management of cross-functional teams.
• Extensive knowledge and experience within managed care organizations, including a comprehensive grasp of quality improvement, utilization management, and disease management.
• In-depth familiarity with healthcare operations, encompassing managed care and government payers, coupled with a nuanced understanding of key healthcare cost and quality drivers.
• Proficiency in interpreting healthcare performance data to identify areas for improvement and drive strategic decision-making.
• Comprehensive understanding of regulations concerning data submission for Medicare Advantage, MMP, and Marketplace risk adjustment.
• Adeptness in coding, Hierarchical Condition Categories (HCCs), risk adjustment and quality concepts, medical record review project management, encounter data management, and compliance audit principles.
• Excellent presentation and communication skills tailored for diverse internal and external audiences.
• Strong problem-solving abilities, fostering a culture of creativity and innovation to address complex healthcare challenges.
• Demonstrated proficiency in managing multiple priorities and deadlines effectively, with a keen eye for decisive and expedient decision-making.
• Ability to navigate challenging peer situations with a high level of professionalism and efficacy, coupled with a deep appreciation for cultural diversity and sensitivity toward the target population.

• Bachelor’s Degree, required; advanced clinical or non-clinical degree preferred
• Medical Degree from an accredited medical school, preferred
• Active participation in continued post-graduate education and training programs, emphasizing a commitment to professional growth and development.

• 5 years of experience within the healthcare or related field, with a proven track record of progressively advancing leadership roles.
• Prior involvement in CMS risk adjustment and quality projects, underscoring a deep understanding of the regulatory landscape and healthcare dynamics

Department: Administration
This is a management position
This is a full time position