What are the responsibilities and job description for the Manager, Clinical Operations - Risk Adjustment & Quality position at Blue Zones Health?
Description
About Blue Zones Health
Blue Zones Health is a lifestyle-first well-being organization that partners with primary care providers and health plans to deliver whole-person care that improves outcomes, reduces unnecessary utilization, and supports patients beyond the four walls of the clinic. Our model integrates lifestyle medicine, health coaching, and social support to address the real drivers of health—especially social, behavioral, and environmental needs.
We work in the real world of healthcare data: eligibility files, claims, enrollment lists, utilization metrics, and financial reporting—often pulled from legacy systems that were never designed for agility. This role exists to both support and modernize this reality.
Position Summary
The Manager, Clinical Operations (Risk Adjustment & Quality) will support the execution and day-to-day management of risk adjustment, coding integrity, and quality improvement initiatives for Blue Zones Health. This role is responsible for coordinating operational activities related to annual wellness visits, coding and documentation accuracy, HEDIS and STARs performance, vendor management, reporting, and quality improvement efforts across multiple health plan partnerships.
The Manager will work closely with internal teams, providers, and external vendors to support operational performance, maintain compliance with regulatory requirements, and drive continuous improvement initiatives.
Key Responsibilities
Risk Adjustment & Coding Support
Qualifications
About Blue Zones Health
Blue Zones Health is a lifestyle-first well-being organization that partners with primary care providers and health plans to deliver whole-person care that improves outcomes, reduces unnecessary utilization, and supports patients beyond the four walls of the clinic. Our model integrates lifestyle medicine, health coaching, and social support to address the real drivers of health—especially social, behavioral, and environmental needs.
We work in the real world of healthcare data: eligibility files, claims, enrollment lists, utilization metrics, and financial reporting—often pulled from legacy systems that were never designed for agility. This role exists to both support and modernize this reality.
Position Summary
The Manager, Clinical Operations (Risk Adjustment & Quality) will support the execution and day-to-day management of risk adjustment, coding integrity, and quality improvement initiatives for Blue Zones Health. This role is responsible for coordinating operational activities related to annual wellness visits, coding and documentation accuracy, HEDIS and STARs performance, vendor management, reporting, and quality improvement efforts across multiple health plan partnerships.
The Manager will work closely with internal teams, providers, and external vendors to support operational performance, maintain compliance with regulatory requirements, and drive continuous improvement initiatives.
Key Responsibilities
Risk Adjustment & Coding Support
- Support the implementation and ongoing management of risk adjustment programs across business lines to promote accurate and compliant coding practices.
- Coordinate provider coding education initiatives, chart reviews, and audit activities to improve documentation accuracy.
- Partner with external coding vendors and internal clinical documentation teams to support operational goals and issue resolution.
- Assist with reconciliation, reporting, and encounter submission processes to identify and address coding gaps.
- Support the execution and monitoring of quality improvement initiatives, including HEDIS, STARs, and health plan-specific programs.
- Coordinate annual wellness visit (AWV) activities, including outreach tracking, scheduling support, completion monitoring, and documentation follow-up.
- Monitor performance against established quality benchmarks and assist with action plans to improve outcomes.
- Collaborate with provider groups and internal stakeholders to support quality improvement and member experience initiatives.
- Maintain operational dashboards, reports, and KPIs to monitor program performance and support accountability.
- Assist with vendor oversight, including performance tracking, issue escalation, and operational coordination.
- Partner cross-functionally with Compliance, Finance, Clinical, and Operations teams to support organizational priorities and regulatory requirements.
- Identify process improvement opportunities and help implement operational efficiencies.
- Support compliance with CMS guidelines, DHCS standards, NCQA/HEDIS protocols, Knox-Keene requirements, and other applicable regulations.
- Participate in internal audit and monitoring activities related to coding, documentation, and quality programs.
- Maintain current knowledge of risk adjustment, coding, and quality program requirements and best practices.
Qualifications
- Bachelor’s degree in Nursing, Health Administration, Public Health, or related field required.
- CPC or CRC certification
- CPMA or other relevant certification preferred.
- LVN or RN preferred
- Minimum 5–7 years of experience in clinical operations, risk adjustment, quality improvement, or managed care operations within a health plan, IPA, or medical group environment.
- Working knowledge of Medicare Advantage, Medi-Cal, risk adjustment, HEDIS, and STARs programs.
- Experience coordinating projects, vendors, or operational initiatives in a healthcare environment.
- Strong analytical, organizational, and problem-solving skills.
- Excellent communication and collaboration skills with providers, vendors, and internal stakeholders.
- Strong organizational and project management skills with the ability to manage multiple priorities.
- Effective communication, facilitation, and relationship-building abilities.
- Ability to analyze operational data and identify actionable insights.
- Collaborative mindset with the ability to work across departments and teams.
- Proficiency in Microsoft Office Suite and project management tools (e.g., Asana, Smartsheet, Trello).
- Detail-oriented with a proactive and solution-focused approach.