Senior Director, Risk Adjustment and Medicare Stars Program Leader

4 weeks ago


Woodland Hills, California, United States Blue Shield of California Full time
About the Role

The Senior Director, Risk Adjustment and Medicare Stars, will lead the development and implementation of the Medicare Risk Adjustment and Stars programs, driving revenue growth and financial viability for Blue Shield of California's Medicare products. This strategic leader will partner with C-suite executives and cross-functional senior leaders to design and execute a national strategy that optimizes encounter data and member quality outcomes.

Key Responsibilities
  • Develop and execute a national strategy for Medicare Risk Adjustment and Stars programs, ensuring alignment with Blue Shield of California's business objectives.
  • Lead the development of risk adjustment and Stars strategies, including the design and implementation of data analytics and reporting tools.
  • Partner with health plan executives to refine and drive strategic improvements, maintaining relationships with external stakeholders and vendors.
  • Direct and oversee risk adjustment and Stars operations, including audit preparation, risk mitigation, and data analysis to support revenue accruals.
  • Establish goals and policies with operational and analytics teams, continually challenging leaders to evaluate processes and capabilities to improve efficiencies and performance.
  • Collaborate with network leadership and support vendor/provider partnerships to drive revenue enhancement programs.
  • Manage universal relationship strategy for vendor relationships, including performance management and process improvements.
  • Oversee program governance and management, including evaluating operational metrics and developing new metrics as necessary.
Requirements
  • Bachelor's 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.
  • 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.
What We Offer

Blue Shield of California offers a competitive salary range of $206,470.00 to $309,650.00 for California, as well as opportunities for professional growth and development. We are an equal opportunity employer and welcome applications from diverse candidates.



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