Vice President, Risk Adjustment and Quality

Description

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.   

Who Are We? ✨ 

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us? 🏆 

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. 

Job Summary

Accountable for developing continuous improvement strategies and directing implementation that delivers operational excellence, resulting in high performance in CMS Star and Medicare Risk Adjustment (MRA) program. Support activities and processes related to compliance with CMS, HPMS, NCQA, local, state, and federal regulatory authorities. Manage the MRA Sweeps and encounter data submission activities along with managing annual HEDIS submission for Managed Care Organizations, Medicare Star, HOS, CAHPS, and other regulatory and contractual compliance. Provide oversight and leadership of Quality Management, including Behavioral Health, Performance Improvement and initiatives, Regulatory Quality Programs, and Member Engagement functional areas. Ensure cross-functional collaboration that meets the accurate & appropriate codes submission goal and also improves quality of care delivery, member experience and outcomes.

Functions & Job Responsibilities

· Develop strategy and tactical processes, in collaboration with the Clever Care’s internal teams and Physicians/IPA/MSO partners, to operationalize and execute MRA and HEDIS/Star procedures including, but not limited to, prospective programs, concurrent/retrospective review, submissions, submission reconciliation, quality control and compliance.

· Oversee the formulation, direction, implementation, administration, supervision, and planning of enterprise-wide performance measurement-based strategies relative to MRA and Quality measures.

· Drive the definition, measurement, and implementation of process improvement activities and projects in support of corporate goals.

· Direct the review and analysis of data to evaluate clinical and administrative service improvement activities and programs.

· Evolve MRA and Star program strategy to achieve improved and cost-effective results, while eliminating sources of uncertainty.

· Design, implement, and monitor incentive programs for both Quality and Risk Adjustment initiatives, ensuring alignment with organizational goals and CMS compliance.

· Develop performance-based incentive structures for providers, IPAs, and internal teams to improve HEDIS, CAHPS, HOS, and Risk Adjustment outcomes.

· Analyze incentive program effectiveness through data-driven metrics and adjust strategies to maximize impact on Star Ratings and MRA performance

· Partner with IT and Data Analytics teams to optimize risk adjustment models, predictive analytics, and dashboard reporting

· Oversee all critical program vendors, including setting the strategy on outsourcing vs. insourcing, assessing new partner opportunities, initiating new relationships, and managing performance of existing partners.

· Responsible for ensuring that the definition and formulation of data-driven strategies, as well as the management and operational activities across Quality Management, Medical Management, Pharmacy Services, and other areas of the organization are designed to increase Clever Care Health Plan quality ratings (Medicare Star Ratings, Quality Incentive Awards, and Quality Rankings) occurs in an efficient and effective manner, and in compliance with NCQA, state and federal regulations and requirements.

· Spearhead the AWV and in-home vendor programs’ execution with appropriate tactics and reporting requirements in place.

· Oversee chart retrieval programs completed by vendor and internal teams.

· Oversee coding and documentation, provider education, sweeps & RADV audit programs and processes.

· Manage HCC improvement and encounter error research/resolution projects.

· Improve core process efficiency, effectiveness, and responsiveness; measure and improve business critical operational KPIs/metrics, especially in the areas of member satisfaction/loyalty/retention, and provider access and availability.

· Direct the application of the Customer and Business data to scope the level of improvement required to impact MRA programs, Star ratings, customer experience and loyalty and bottom-line results.

· Work with appropriate entities (internal or external) to reduce encounter/claims rejects from CMS, any vendor projects, and clearing house(s).

· Support the implementation of the Member Rewards Program implementation and ongoing monitoring across the enterprise.

· Oversee the department’s member engagement efforts by developing year-round campaign strategy and parameters.

· Oversee the Quality and STARS teams to ensure optimal results are obtained for the CMS Stars program including HEDIS measures, CAHPS and HOS scores.

· Partner with Operations teams to improve the member experience as measure in the Stars program.

· Oversee team that investigates and resolves/tracks quality of care issues that come from members/providers/UM process.

· Other duties as assigned.

Leadership Expectations

By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

1. Model the Way:

• Clarify values by finding your voice and affirming shared values

• Set the example by aligning actions with shared values

2. Inspire a Shared Vision

• Envision the future by imagining and sharing exciting possibilities

• Enlist others in a common vision by appealing to shared ambitions

3. Challenge the Process

• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve

• Experiment and take risks by consistently generating small wins and learning from experience

4. Enable Others to Act

• Foster collaboration by building trust and facilitating relationships

• Strengthen others by increasing self-determination and developing competence

5. Encourage the Heart

• Recognize contributions by showing appreciation for individual excellence

• Celebrate the values and victories by creating a spirit of community

Qualifications

Qualifications

Education and Experience

· Bachelor’s degree in Business, Healthcare, or related field required. Master’s degree preferred.

· Minimum seven (7) years’ experience in healthcare/managed care industry with experience in Medicare Risk Adjustment (MRA), HEDIS/Star/CAHPS and HOS program management and leadership.

· Experience in program performance measurement, analytics, reporting and forecasting for MRA & Quality programs/measures.

Professional Certifications (Preferred)

· Certified Professional in Healthcare Quality (CPHQ)

· Certified Risk Adjustment Coder (CRC)

· Project Management Professional (PMP)

Skills

· Ability to effectively communicate in multiple formats to varied audiences (leadership, clinicians, office staff, etc.) on a variety of complex topics.

· Knowledge, understanding, and accurate interpretation of product line related specifications, methodologies, and processes, and of MRA/HEDIS/Star processes.

· Excellent leadership skills and the ability to influence line management decisions with data driven facts.

· Strong management, problem solving, priority setting skills.

· Strong independent decision-making skills

· Strong organizational skills including time and project management skills.

· Computer proficiency in MS Office applications (word processing, spreadsheet/database, presentation)

· Possess strong results-oriented process improvement capabilities.

· Strong problem solving and analytical skills to be applied to a wide array of business problems and challenges.

· Detail oriented with exceptional written and verbal communication skills.

· Ability to maintain composure and effectiveness in a rapidly changing environment with minimum direction.

· Must be a self-starter and independent thinker.

Wage Range: $200,000 - $250,000 per year

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required

• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)

• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

 

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

 

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

 

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. 

  

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency. 

 

#LI-Hybrid

Salary : $200,000 - $250,000