Senior Director, Risk Adjustment and Medicare STARs

Your Role

The Senior Director, Risk Adjustment and Medicare STARs role will lead the Medicare Risk Adjustment and Stars programs, two functions that drive appropriate revenue and thus critical to the growth and financially viable and competitive Medicare products. This leader will develop the programs and take accountability by partnering with C-suite executive and cross functional senior leaders across multiple health plans (national) for better encounter data and member quality outcomes (including member/provider education and engagement initiatives, vendor management). This strategic leader ensures accurate coding accuracy and submission of health conditions for beneficiaries in Medicare Advantage plans. The program will have oversight of encounter data processes as well as retrospective and prospective initiatives. The Senior Director is accountable for preparation for and management of the Center for Medicare and Medicaid Services (CMS) auditing processes and management of applicable state and federal guidance. The Risk Adjustment Program is critical as it ensures that the health conditions of the beneficiaries in a Medicare Advantage plan are accurately captured. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• Bachelors degree in Health Administration, Business, Finance or related field; Master's degree preferred
• Minimum ten (10) years experience in a combination of quality, provider engagement and/risk adjustment, with at least 6 years in a senior leadership role
• Minimum of ten (10) or more years of current progressive, operational experience in a health plan or managed care setting with a focus on excellent process and execution. Five (5) years of strong senior level leadership/management experience is required
• Demonstrated knowledge of Center for Medicare and Medicaid Services (CMS) practices, policies, and regulations
• Experience with strategy development, execution, planning, and management of high priority/high visibility projects related to corporate enterprise efforts
• Proven track record of developing and implementing successful Risk Adjustment and Stars processes and regulations
• In-depth knowledge of Medicare Advantage, Risk Adjustment processes and regulations
• Excellent leadership and team management abilities with a history of developing high performing teams
• Experience with managed care software and analytics tools
• Process improvement knowledge and experience
• Comprehensive knowledge of payer environment and healthcare systems
• Strong financial management, organizational, negotiation, analytic, problem solving and management skills, with the ability to interpret complex data
• Effective communication and interpersonal skills, with the ability to influence stakeholders at all levels
• Demonstrated track record of driving large-scale business change, particularly in a matrix environment

Pay Range:

The pay range for this role is: $206,470.00 to $309,650.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.